Phosphor-containing drug activator activatable by a Monte Carlo derived x-ray exposure, system containing the activator, and methods for use

ABSTRACT

A phosphor-containing drug activator activatable from a Monte Carlo derived x-ray exposure for treatment of a diseased site. The activator includes an admixture or suspension of one or more phosphors capable of emitting ultraviolet and visible light upon interaction with x-rays, wherein a distribution of the phosphors in the diseased target site is based on a Monte Carlo derived x-ray dose. A system for treating a disease in a subject in need thereof, includes the drug activator and a photoactivatable drug, one or more devices which infuse the photoactivatable drug and the activator including the pharmaceutically acceptable carrier into a diseased site in the subject; and an x-ray source which is controlled to deliver the Monte Carlo derived x-ray exposure to the subject for production of ultraviolet and visible light inside the subject to activate the photoactivatable drug.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. provisional Ser. No.62/425,386, filed Nov. 22, 2016, the entire contents of which are herebyincorporated by reference. This application is related to U.S.provisional Ser. No. 61/982,585, filed Apr. 22, 2014, entitled “INTERIORENERGY-ACTIVATION OF PHOTO-REACTIVE SPECIES INSIDE A MEDIUM OR BODYUSING AN X-RAY SOURCE EMITTING LOW ENERGY X-RAYS AS INITIATION ENERGYSOURCE”, the entire contents of which are hereby incorporated byreference. This application is related to provisional Ser. No.62/096,773, filed: Dec. 24, 2014, entitled “INTERIOR ENERGY-ACTIVATIONOF PHOTO-REACTIVE SPECIES INSIDE A MEDIUM OR BODY USING AN X-RAY SOURCEEMITTING LOW ENERGY X-RAYS AS INITIATION ENERGY SOURCE,” the entirecontents of each of which is incorporated herein by reference. Thisapplication is related to U.S. provisional Ser. No. 62/132,270, filedMar. 12, 2015, entitled “TUMOR IMAGING WITH X-RAYS AND OTHER HIGH ENERGYSOURCES USING AS CONTRAST AGENTS PHOTON-EMITTING PHOSPHORS HAVINGTHERAPEUTIC PROPERTIES”, the entire contents of which are herebyincorporated by references. This application is related to U.S.provisional Ser. No. 62/147,390, filed Apr. 14, 2015, entitled “TUMORIMAGING WITH X-RAYS AND OTHER HIGH ENERGY SOURCES USING AS CONTRASTAGENTS PHOTON-EMITTING PHOSPHORS HAVING THERAPEUTIC PROPERTIES”, theentire contents of which are hereby incorporated by references.

This application is related to provisional U.S. Ser. No. 12/401,478 (nowU.S. Pat. No. 8,376,013) entitled “PLASMONIC ASSISTED SYSTEMS ANDMETHODS FOR INTERIOR ENERGY-ACTIVATION FROM AN EXTERIOR SOURCE, filedMar. 10, 2009, the entire contents of which are incorporated herein byreference. This application is related to U.S. Ser. No. 13/102,277entitled “ADHESIVE BONDING COMPOSITION AND METHOD OF USE,” filed May 6,2011, the entire contents of which are incorporated herein by reference.This application is related to provisional Ser. No. 61/035,559, filedMar. 11, 2008, and entitled “SYSTEMS AND METHODS FOR INTERIORENERGY-ACTIVATION FROM AN EXTERIOR SOURCE,” the entire contents of whichare hereby incorporated herein by reference. This application is relatedto provisional Ser. No. 61/030,437, filed Feb. 21, 2008, entitled“METHODS AND SYSTEMS FOR TREATING CELL PROLIFERATION DISORDERS USINGPLASMONICS ENHANCED PHOTOSPECTRAL THERAPY (PEPST) AND EXCITON-PLASMONENHANCED PHOTOTHERAPY (EPEP),” the entire contents of which are herebyincorporated herein by reference. This application is related tonon-provisional Ser. No. 12/389,946, filed Feb. 20, 2009, entitled“METHODS AND SYSTEMS FOR TREATING CELL PROLIFERATION DISORDERS USINGPLASMONICS ENHANCED PHOTOSPECTRAL THERAPY (PEPST) AND EXCITON-PLASMONENHANCED PHOTOTHERAPY (EPEP),” the entire contents of which are herebyincorporated herein by reference. This application is related tonon-provisional Ser. No. 11/935,655, filed Nov. 6, 2007, entitled“METHODS AND SYSTEMS FOR TREATING CELL PROLIFERATION RELATED DISORDERS,”and to provisional Ser. No. 60/910,663, filed Apr. 8, 2007, entitled“METHOD OF TREATING CELL PROLIFERATION DISORDERS,” the contents of eachof which are hereby incorporated by reference in their entireties. Thisapplication is related to provisional Ser. No. 61/035,559, filed Mar.11, 2008, and entitled “SYSTEMS AND METHODS FOR INTERIORENERGY-ACTIVATION FROM AN EXTERIOR SOURCE,” the entire contents of whichare hereby incorporated herein by reference. This application is alsorelated to provisional Ser. No. 61/792,125, filed Mar. 15, 2013,entitled “INTERIOR ENERGY-ACTIVATION OF PHOTO-REACTIVE SPECIES INSIDE AMEDIUM OR BODY,” the entire contents of which are hereby incorporatedherein by reference. This application is further related to provisionalSer. No. 61/505,849 filed Jul. 8, 2011, and U.S. application Ser. No.14/131,564, filed Jan. 8, 2014, each entitled “PHOSPHORS ANDSCINTILLATORS FOR LIGHT STIMULATION WITHIN A MEDIUM,” the entirecontents of each of which is incorporated herein by reference. Thisapplication is related to and U.S. application Ser. No. 14/206,337,filed Mar. 12, 2014, entitled “INTERIOR ENERGY-ACTIVATION OFPHOTO-REACTIVE SPECIES INSIDE A MEDIUM OR BODY,” the entire contents ofwhich are hereby incorporated herein by reference. This application isrelated to national stage PCT/US2015/027058 filed Apr. 22, 2015,entitled “TUMOR IMAGING WITH X-RAYS AND OTHER HIGH ENERGY SOURCES USINGAS CONTRAST AGENTS PHOTON-EMITTING PHOSPHORUS HAVING THERAPEUTICPROPERTIES,” the entire contents of which are hereby incorporated hereinby reference. This application is related U.S. Ser. No. 62/243,465 filedOct. 19, 2015, entitled “X-RAY PSORALEN ACTIVATED CANCER THERAPY(X-PACT),” the entire contents of which are hereby incorporated hereinby reference. This application is related to U.S. provisional Ser. No.62/290,203, filed Feb. 2, 2016, entitled “PHOSPHOR-CONTAINING DRUGACTIVATOR, SUSPENSION THEREOF, SYSTEM CONTAINING THE SUSPENSION, ANDMETHODS FOR USE”, the entire contents of which are hereby incorporatedby reference. This application is related to U.S. provisional Ser. No.62/304,525, filed Mar. 7, 2016 entitled “PHOSPHOR-CONTAINING DRUGACTIVATOR, SUSPENSION THEREOF, SYSTEM CONTAINING THE SUSPENSION, ANDMETHODS FOR USE”, the entire contents of which are hereby incorporatedby references. This application is related to U.S. provisional Ser. No.62/369,482, filed Aug. 1, 2016 entitled “PHOSPHOR-CONTAINING DRUGACTIVATOR ACTIVATABLE BY A MONTE CARLO DERIVED X-RAY EXPOSURE, SYSTEMCONTAINING THE ACTIVATOR, AND METHODS FOR USE”, the entire contents ofwhich are hereby incorporated by references.

BACKGROUND OF THE INVENTION Field of Invention

The invention relates to methods and systems for treating cellproliferation disorders that can be performed using non-invasive orminimally invasive techniques.

Discussion of the Background

Light modulation from a deeply penetrating radiation like X-ray opensthe possibility for activating bio-therapeutic agents of various kindswithin mammalian bodies. As an example, the binding of psoralen to DNAthrough the formation of monoadducts is well known to engender an immuneresponse if done properly. Psoralen under the correct light activationgains the aptitude to bind to DNA. Psoralen has been reported to reactto other sites that have a suitable reactivity including and not limitedto cell walls. If this reaction is of the correct kind, as is the casefor psoralen-DNA monoadducts formation, the binding leads to aprogrammable cell death referred to as Apoptosis. Such programmable celldeath, if accomplished over a cell population, can signal the body tomount an immune response permitting target specific cell kill throughoutthe body. Such immune response is of importance for various medicaltreatments including cancer treatment.

Psoralens are naturally occurring compounds found in plants(furocoumarin family) with anti-cancer and immunogenic properties. Theyfreely penetrate the phospholipid cellular bilayer membranes andintercalate into DNA between nucleic acid pyrimidines, where they arebiologically inert (unless photo-activated) and ultimately excretedwithin 24 hours. However psoralens are photo-reactive, acquiring potentcytotoxicity after ‘activation’ by ultra-violet (UVA) light. Whenphoto-activated, psoralens form mono-adducts and di-adducts with DNAleading to marked tumor cytotoxicity and apoptosis. Cell signalingevents in response to DNA damage include up-regulation of p21^(waf/Cip)and p53 activation, with mitochondrial induced cytochrome c release andconsequent cell death. Photo-activated psoralen can also induceapoptosis by blocking oncogenic receptor tyrosine kinase signaling, andcan affect immunogenicity and photochemical modification of a range ofcellular proteins in treated cells.

Importantly, psoralen can promote a strong long-term clinical response,as observed in the treatment of cutaneous T Cell Lymphoma utilizingextracorporeal photopheresis (ECP). In ECP malignant CTCL cells areirradiated with ultraviolet A (UVA) light in the presence of psoralen,and then re-administered to the patient. Remarkably, complete long termresponses over many decades have been observed in a sub-set of patients,even though only a small fraction of malignant cells were treated. Inaddition to ECP, psoralens have also found wide clinical applicationthrough PUVA treatment of proliferative skin disorders and cancerincluding psoriasis, vitiligo, mycosis fungoides, and melanoma.

The cytotoxic and immunogenic effects of psoralen are often attributedto psoralen mediated photoadduct DNA damage. A principle mechanismunderlying the long-term immunogenic clinical response likely derivesfrom psoralen induced tumor cell cytotoxicity and uptake of theapoptotic cells by immature dendritic cells, in the presence ofinflammatory cytokines. However, photochemical modification of proteinsand other cellular components can also impact the antigenicity andpotential immunogenicity of treated cells. The diversity and potency ofpsoralen application is further illustrated by recent success usingpsoralen in the development of virus vaccines.

SUMMARY OF THE INVENTION

In one embodiment, the present invention provides a phosphor-containingdrug activator activatable from a Monte Carlo derived x-ray exposureincluding an admixture or suspension of phosphors capable of emittingultraviolet and visible light upon interaction with x-rays; wherein adistribution of the phosphors in a diseased target site or an x-ray doseto the diseased site or both is based on a Monte Carlo derived x-raydose.

In one embodiment, there is provided a system for treating a disease ina subject in need thereof, which includes the drug activator and aphotoactivatable drug, one or more devices which infuse thephotoactivatable drug and the activator including the pharmaceuticallyacceptable carrier into a diseased site in the subject; and an x-raysource which is controlled to deliver a Monte Carlo derived x-rayexposure to the subject for production of ultraviolet and visible lightinside the subject to activate the photoactivatable drug and induce apersistent therapeutic response, the dose comprising a pulsed sequenceof x-rays delivering from 0.5-2 Gy to the tumor.

In one embodiment, there is provided a system for treating a disease ina subject in need thereof, which includes a phosphor-containing drugactivator and a photoactivatable drug, one or more devices which infusethe photoactivatable drug and the activator into a diseased site in thesubject; and an x-ray source which is controlled to deliver a MonteCarlo derived x-ray exposure to the subject for production ofultraviolet and visible light inside the subject to activate thephotoactivatable drug.

It is to be understood that both the foregoing general description ofthe invention and the following detailed description are exemplary, butare not restrictive of the invention.

BRIEF DESCRIPTION OF THE FIGURES

A more complete appreciation of the invention and many of the attendantadvantages thereof will be readily obtained as the same becomes betterunderstood by reference to the following detailed description whenconsidered in connection with the accompanying drawings, wherein:

FIG. 1A illustrates a system according to one exemplary embodiment ofthe present invention;

FIG. 1B is a flow diagram for one process of the invention formanufacturing the phosphor-containing device;

FIG. 2 is a depiction of cathodoluminescence data for Zn₂SiO₄:Mn²⁺measured between 100-400 nm;

FIG. 3 is a depiction of cathodoluminescence data for Zn₂SiO₄:Mn²⁺measured between 450-700 nm;

FIG. 4 is a depiction of cathodoluminescence data for (3Ca₃(PO₄)₂.Ca(F,Cl)₂: Sb³⁺, Mn²⁺) measured between 100-400 nm;

FIG. 5 is a depiction of cathodoluminescence data for (3Ca₃(PO₄)₂.Ca(F,Cl)₂: Sb³⁺, Mn²⁺) measured between 450-700 nm;

FIG. 6 is an illustration of a combination phosphor device having a dualcoating;

FIG. 7 is an illustration of a combination phosphor device having a 2:1ratio with one part of Zn₂SiO₄:Mn²⁺ for every two parts of(3Ca₃(PO₄)₂.Ca(F, Cl)₂: Sb³⁺;

FIG. 8 is a photographic depiction of a packaged device kit according toone embodiment of the invention;

FIGS. 9A, 9B, 9C, 9D-1, and 9D-2 show graphs showing tumor volume as afunction of days after treatment for an in-vivo treatment of BALBC micewith syngeneic 4T1-HER2 tumors, as well as photographs of tumors beingtreated during the course of treatment;

FIG. 10 is a plot summarizing the fractional cell kills as a function ofkVp for a fixed amperage of 200 mA;

FIG. 11 is a photographic depiction showing of methylene blue stainingfor cell viability post treatment with x-rays, phosphors, and UVADEX;

FIG. 12 is a plot summarizing the fractional cell kills under differentx-ray exposure cycles;

FIGS. 13A, 13B, 13C, and 13D illustrate the efficacy of a treatmentin-vitro against 4T1-HER2 cells;

FIGS. 14A and 14B are illustrations of the relative effectiveness of UVactivated psoralen on three independent cell lines;

FIGS. 15A and 15B are illustrations of the anti-tumor effects of thex-ray psoralen activated cancer therapy (XPACT) treatment and individualcomponents on 4T1-HER2 cells;

FIG. 16 is a comparison of the phosphor-containing drug activator at twodifferent x-ray energies (80 and 100 kVp) for 4T1-HER2 cells treatedwith 8-MOP;

FIGS. 17A and 17B are photographic depictions showing the efficacy ofthe phosphor-containing drug activator during a canine studypre-treatment and post-treatment on Subject #1, respectively;

FIGS. 18A and 18B are further photographic depictions showing theefficacy of the phosphor-containing drug activator during the caninestudy pre-treatment and post-treatment on Subject #2, respectively;

FIG. 19 is a composite micrograph showing a cone-beam computedtomography (CBCT) image in different perspectives and a FlukaFlairsimulation of the radiation dose received in the canine;

FIG. 20A is a schematic depiction of the x-ray source geometry;

FIG. 20B is a schematic depiction of a simulated 80 KVp x-ray energyspectrum emanating from the OBI device;

FIG. 21 is a schematic depiction of x-ray device modeling showingverification of the MC simulation results by measurements of the halfvalue layer for different thicknesses of aluminum and the percent depthdose (PDD) in a water phantom;

FIG. 22 is a composite schematic showing verification of the MCsimulations with respect to the off-axis ratio (OAR) of the x-ray energyspectrum;

FIG. 23 is a composite schematic showing verification of the MCsimulations with respect to the back scattered factor (BSF) of the x-rayenergy spectrum emanating from the OBI device at 80 KVp and depositingits energy in a water phantom;

FIG. 24 is a plot of relative dose in air as a function of field size(Sc) for 80 kVp source at 50 SSD;

FIG. 25 is a schematic showing comparative plots of the ratio of dose onwater surface to dose in air at the same position (backscatter factor),for the 80 kVp source with a source to detector distance of 50 cm;

FIG. 26 is a schematic depiction of depth dose curves for 80 kVp sourceat 80 cm source to surface distance for 3 cm, 8 cm, and 32 cm fieldsizes (defined at surface) and normalized at a depth of 1 cm;

FIG. 27 is a composite schematic showing verification of the MCsimulations with respect to the off-axis ratio (OAR) of the x-ray energyspectrum emanating from the OBI device at 80 KVp;

FIGS. 28A and 28B show respectively the setup of the dog in the room(first image) and the 3D model of the anatomy from a CBCT (secondimage);

FIG. 29 is a composite depiction showing a final dose calculation usingMonte Carlo modeling and canine CBCT for example case in FIGS. 28A and28B.

DETAILED DESCRIPTION OF THE INVENTION

The present invention sets forth a novel method of treating cellproliferation disorders that is effective, specific, and has fewside-effects. In one embodiment of the present invention, the treatmentsand protocols described below are performed with the assistance ofpre-planned Monte Carlo derived x-ray exposures (detailed below). TheMonte Carlo derived x-ray exposures in one embodiment of the inventionpermit the settings of the x-ray source and its dose energy and doseflux to be optimized for the location and distribution of the tumor (ordiseased site) within the body.

As used herein, the phrase “cell proliferation disorder” refers to anycondition where the growth rate of a population of cells is less than orgreater than a desired rate under a given physiological state andconditions. Although, preferably, the proliferation rate that would beof interest for treatment purposes is faster than a desired rate, slowerthan desired rate conditions may also be treated by methods of theinvention. Exemplary cell proliferation disorders may include, but arenot limited to, cancer, bacterial infection, immune rejection responseof organ transplant, solid tumors, viral infection, autoimmune disorders(such as arthritis, lupus, inflammatory bowel disease, Sjogrenssyndrome, multiple sclerosis) or a combination thereof, as well asaplastic conditions wherein cell proliferation is low relative tohealthy cells, such as aplastic anemia. Particularly preferred cellproliferation disorders for treatment using the present methods arecancer, staphylococcus aureus (particularly antibiotic resistant strainssuch as methicillin resistant staphylococcus aureus or MRSA), andautoimmune disorders.

Those cells suffering from a cell proliferation disorder are referred toherein as the target cells. A treatment for cell proliferationdisorders, including solid tumors, is capable of chemically bindingcellular nucleic acids, including but not limited to, the DNA ormitochondrial DNA or RNA of the target cells. For example, aphotoactivatable agent, such as a psoralen or a psoralen derivative, isexposed in situ to an energy source (e.g., x-rays) capable of activatingenergy modulation agents (e.g., phosphors) which emit light to activatephotoactivatable agents such as psoralen or coumarin.

The terminology used in the description of the invention herein is forthe purpose of describing particular embodiments only and is notintended to be limiting of the invention. As used in the description ofthe embodiments of the invention and the appended claims, the singularforms “a”, “an” and “the” are intended to include the plural forms aswell, unless the context clearly indicates otherwise. Also, as usedherein, “and/or” refers to and encompasses any and all possiblecombinations of one or more of the associated listed items. Furthermore,the terms “at” or “about,” as used herein when referring to a measurablevalue or metric is meant to encompass variations of 20%, 10%, 5%, 1%,0.5%, or even 0.1% of the specified amount, for example a specifiedratio, a specified thickness, a specified phosphor size, or a specifiedwater contact angle. It will be further understood that the terms“comprises” and/or “comprising,” when used in this specification,specify the presence of stated features, integers, steps, operations,elements, and/or components, but do not preclude the presence oraddition of one or more other features, integers, steps, operations,elements, components, and/or groups thereof.

The present invention in one embodiment utilizes x-ray driven activationof 8MOP (or UVADEX) to induce a persistent anti-tumor response and aresulting arrest of tumor growth or regression. As used herein, apersistent antitumor response is a response which slows or stops thetumor growth from that of a control or blind subject receiving only aplacebo. The present invention demonstrates that x-ray driven activationof a photoactivatable drug (e.g., 8MOP) slows tumor growth in some casesand in other cases arrests growth of the tumor leading to signs ofcomplete remission for the subject.

In particular, the present invention in one embodiment utilizes a novelphosphor-containing drug activator for causing a change in activity in asubject that is effective, specific, and able to produce a change to themedium or body. The phosphor-containing drug activator in one embodimentcomprises a mixture of two different phosphors, which upon x-rayexcitation, each have emissions in the UV and visible spectrum. Themixture of phosphors results in superior performance compared to eitherphosphor alone. The mixture of phosphors preferably includes a mixtureof two or more phosphors, namely NP-200 and GTP-4300, that are purchasedfrom Nichia and Global Tungsten and Powders, respectively. The chemicalformulas of these phosphors are Zn₂SiO₄:Mn²⁺ and (3Ca₃(PO₄)₂Ca(F, Cl)₂:Sb³⁺, Mn²⁺), respectively. These phosphors absorb penetrating forms ofenergy (e.g., low dose x-rays) and emit light in wavelengths thatactivate the 8MOP (or UVADEX) in-situ. In one embodiment of theinvention, the phosphors in the novel phosphor-containing drug activatorare coated with a biocompatible Ethyl Cellulose coating and/or coatedwith a Diamond Like Carbon (DLC) coatings. The coatings are describedbelow.

As used herein, the phrase “Monte Carlo derived x-ray exposures” refersto the setting of x-ray conditions (beam amperage, kVp, collimators,aperture opening) based on Monte Carlo simulations of one or more of thex-ray source, the patient treatment area, and the phosphor type anddistribution, the bone mass, and the tumor mass.)

Reference will now be made in detail to the preferred embodiments of theinvention, examples of which are illustrated in the accompanyingdrawings (including color drawings), in which like reference charactersrefer to corresponding elements.

FIG. 1A illustrates a system according to one exemplary embodiment ofthe invention. Referring to FIG. 1A, an exemplary system according toone embodiment of the invention may have an initiation energy source 1directed at the subject 4. An activatable pharmaceutical agent 2 and theabove-noted phosphor-containing drug activator 3 can be administered tothe subject 4 by way of a sterile suspension of two or more of theabove-noted phosphors. The initiation energy source may additionally becontrolled by a computer system 5 that is capable of directing thedelivery of the initiation energy (e.g., X-rays).

Computer system 5, in one embodiment of the present invention, isprogrammed with the protocol-based information for treating a disease ina subject in need thereof. The protocol-based information includes aquantity and type of phosphor-containing drug activator and a quantityand type a photoactivatable drug. The protocol-based information caninclude details in the types of devices which can be used to infuse thephotoactivatable drug and the activator (including optionalpharmaceutically acceptable carriers) into a diseased site in thesubject. The protocol-based information can optionally includeinformation on an x-ray source and how it is to be controlled to delivera pre-planned Monte Carlo derived x-ray exposure to the subject forproduction of ultraviolet and visible light inside the subject toactivate the photoactivatable drug and preferably induce a persistenttherapeutic response.

In further embodiments, dose calculation and robotic manipulationdevices (such as the CYBER-KNIFE robotic radiosurgery system, availablefrom Accuray, or similar types of devices) may be included in the systemto adjust the distance between the initiation energy source 1 and thesubject 4 and/or to adjust the energy and/or dose (e.g., kVp orfiltering) of the initiation energy source such that the x-rays incidenton the target site are within a prescribed energy band. Furtherrefinements in the x-ray energy and dose can be had by adjusting thedistance to the subject 4 or the intervening materials between thetarget site and the initiation energy source 1. The initiation energysource 1 (i.e., an X-ray source) can provide images of the target areabeing treated.

In various embodiments, the initiation energy source 1 may be a linearaccelerator equipped with at least kV image guided computer-controlcapability to deliver a precisely calibrated beam of radiation to apre-selected coordinate. One example of such linear accelerators is theSMARTBEAM™ IMRT (intensity modulated radiation therapy) system (fromVarian Medical Systems, Inc., Palo Alto, Calif.) or Varian OBItechnology (OBI stands for “On-board Imaging”, and is found on manycommercial models of Varian machines). In other embodiments, theinitiation energy source 1 may be commercially available components ofX-ray machines or non-medical X-ray machines. X-ray machines thatproduce from 10 to 150 keV X-rays are readily available in themarketplace. For instance, the General Electric DEFINIUM series or theSiemens MULTIX series are two non-limiting examples of typical X-raymachines designed for the medical industry, while the EAGLE PACK seriesfrom Smith Detection is an example of a non-medical X-ray machine.Another suitable commercially available device is the SIEMENS DEFINITIONFLASH, (a CT system), by Siemens Medical Solutions. As such, theinvention is capable of performing its desired function when used inconjunction with commercial X-ray equipment.

In a particularly preferred embodiment, the initiation energy source 1is a source of low energy x-rays, of 300 kVp or lower, e.g., at or below300 kVp, at or below 200 kVp, at or below 120 kVp, at or below 105 kVp,at or below 80 kVp, at or below 70 kVp, at or below 60 kVp, at or below50 kVp, at or below 40 kVp, at or below 30 kVp, at or below 20 kVp, ator below 10 kVp, or at or below 5 kVp. In this embodiment, theinitiation energy source provides low energy x-rays which are convertedby the phosphor-containing drug activator 3 in situ to an energy capableof activating 8MOP (or UVADEX).

In one embodiment of the invention, the phosphors in thephosphor-containing drug activator are first coated with a biocompatibleEthyl Cellulose coating, and then overcoated with a second coating ofDiamond Like Carbon (DLC). In one embodiment of the invention, thephosphors in the phosphor-containing drug activator are coated only withthe Ethyl Cellulose coating or the DLC coating.

Ethyl Cellulose (EC) is widely used in biomedical applications today,including artificial kidney membranes, coating materials for drugs,blood coagulants, additives of pharmaceutical products, blood compatiblematerials. EC and its derivatives have been widely used in various,personal care, food, biomedical and drug related applications. EC is nota skin sensitizer, it is not an irritant to the skin, and it is notmutagenic. EC is generally regarded as safe (GRAS), and widely used forexample in food applications such flavor encapsulation, inks for makingfruits and vegetables, paper and paperboard in contact with aqueous andfatty foods.

EC is also widely used for controlled release of active ingredients. Theenhanced lipophilic and hydrophobic properties make it a material ofchoice for water resistant applications. EC is soluble in variousorganic solvents and can form a film on surfaces and around particles(such as phosphors). In one embodiment of this invention, ethylcellulose is used to encapsulate the phosphors particles of thephosphor-containing drug activator to ensure that an added degree ofprotection is in place on the surface of the phosphors. In oneembodiment of this invention, EC polymers with high molecular weight forpermanent encapsulation and long term biocompatibility are used toencapsulate the phosphors particles of the phosphor-containing drugactivator. In a preferred embodiment, the EC polymer can be anycommercially available pharmaceutical grade ethyl cellulose polymerhaving sufficient molecular weight to form a coating on the phosphorsurface. Suitable EC polymers include, but are not limited to, theETHOCEL brand of ethyl cellulose polymers available from Dow Chemical,preferably ETHOCEL FP grade products, most preferably ETHOCEL FP 100.

Diamond Like Carbon (DLC) films are in general dense, mechanically hard,smooth, impervious, abrasion resistant, chemically inert, and resistantto attack by both acids and bases; they have a low coefficient offriction, low wear rate, are biocompatible and thromboresistant. Tissuesadhere well to carbon coated implants and sustain a durable interface.In presence of blood, a protein layer is formed which prevents theformation of blood clots at the carbon surface. For medical prosthesesthat contact blood (heart valves, anathomic sheets, stents, bloodvessels, etc.), DLC coatings have been used.

DLC has emerged over the past decade as a versatile and usefulbiomaterial. It is harder than most ceramics, bio-inert, and has a lowfriction coefficient. DLC is one of the best materials for implantableapplications. Studies by the inventors of the biocompatibility of DLCdemonstrate that there is no cytotoxicity and cell growth is normal on aDLC-coated surface. (DLC coatings on stainless steel have performed verywell in in vitro studies of hemocompatibility. Histopathologicalinvestigations by the inventors have shown good biotolerance of implantscoated with the DLC. Moreover, DLC as a coating is efficient protectionagainst corrosion. These properties make the embodiment described herewith a double coating (EC and DLC) particularly advantageous for thenovel phosphor-containing drug activator of the invention.

Methods for coating the phosphors with EC or DLC are known to those ofordinary skill, and have been described, for example, inPCT/US2015/027058 filed Apr. 22, 2015, incorporated earlier byreference.

Manufacturing Process Steps

FIG. 1B is a flow diagram for one process of the invention formanufacturing the novel phosphor-containing drug activator using the rawmaterials noted in Table 1 below. (The present invention is not limitedto the various steps described below in the illustrative manufacturingprocess. The steps merely provide specific ways that these steps canoccur.)

TABLE 1 Raw Materials Item Description/Name Manufacturer Phosphor GTP4300 Global Tungsten and Powders Phosphor NP200 Nichia Ethyl CelluloseDow Chemical Co Acetone Thermo Fisher Diamond like carbon (DLC)Fraunhoffer

As shown in FIG. 1B, manufacturing of the novel phosphor-containing drugactivator of the invention starts with quality control of the rawmaterials. As part of quality control, in one embodiment of theinvention, the raw materials utilized in the novel phosphor-containingdrug activator are characterized with one or more of the following suiteof tests:

-   -   X-Ray Diffraction (XRD) to confirm the crystallography type;    -   X-Ray Photoelectron Spectroscopy (XPS) for surface elemental        analysis;    -   Inductively Coupled Plasma (ICP) for total elemental analysis;    -   Scanning Electron Microscopy (SEM) for particle size        determination;    -   Cathodoluminescence for UV/VIS emissions

X-ray diffraction (XRD) is nondestructive technique for characterizingcrystalline materials. It provides information on structures, phases,preferred crystal orientations (texture), and other structuralparameters, such as average grain size, crystallinity, strain, andcrystal defects. The x-ray diffraction pattern is a fingerprint ofperiodic atomic arrangements in a given material. A comparison of anobserved diffraction pattern to a known reference material allowsconfirmation of the crystal lattice of the solid material. In oneembodiment of the invention, x-ray diffraction peaks matching knownreferences form one acceptance criterion of the invention for furtherprocessing. Preferably, the Zn₂SiO₄:Mn²⁺ phosphor has cathodoluminescentemission peaks at least at 160 nm, 360 nm, and 525 nm, while preferablythe (3Ca₃(PO₄)₂Ca(F, Cl)₂: Sb³⁺, Mn²⁺) phosphor has a cathodoluminescentemission edge at least at 400 nm and a cathodoluminescent emission peakat least at 570 nm.

X-ray Photoelectron Spectroscopy (XPS Analysis), also known as ElectronSpectroscopy for Chemical Analysis (ESCA), is used to determinequantitative atomic composition and chemistry. It is a surface analysistechnique with a sampling volume that extends from the surface to adepth of approximately 50-70 Angstroms. XPS analysis can be utilized tocharacterize thin films by quantifying matrix-level elements as afunction of depth. XPS is an elemental analysis technique that is uniquein providing chemical state information of the detected elements, suchas distinguishing between sulfate and sulfide forms of the elementsulfur. The process works by irradiating a sample with monochromaticx-rays, resulting in the emission of photoelectrons whose energies arecharacteristic of the elements within the sampling volume. In oneembodiment of the invention, XPS is another acceptance criterion of theinvention for further processing in which both the position (energy) ofthe emitted photoelectrons and their relative intensity patterns shouldmatch the reference patterns on file for each inorganic phosphor beingused (e.g. NP200 and GTP430).

In one embodiment of the invention, this analytical method is used todetermine the surface elemental composition of the raw material(s) andsubsequent changes in atomic % of carbon to confirm that both the EC andDLC coating processes are within acceptable tolerances (e.g. up to a25-75% increase in C content for the final EC/DLC autoclave product). Asan acceptance criterion of the invention, emission peaks from Zn, Si,Ca, P, O, F, Cl, Sb, Mn and C should be present and no other elements(such as contaminants) would be present.

Inductively Coupled Plasma (ICP) analytical techniques canquantitatively measure the elemental content of a material from the pptto the wt % range. In this technique, solid samples are dissolved ordigested in a liquid, usually an acidic aqueous solution. The samplesolution is then sprayed into the core of an inductively coupled argonplasma, which can reach temperatures of approximately 8000° C. At suchtemperature, analyte species are atomized, ionized and thermallyexcited. The analyte species is then detected and quantified with a massspectrometer (MS). In one embodiment of the invention, XPS is anotheracceptance criterion of the invention in which both the mass number andintensity (relative quantity) should match reference patterns on filefor each inorganic phosphor used (e.g. NP200 and GTP430).

Scanning Electron Microscopy (SEM) provides high-resolution andlong-depth-of-field images of the sample surface and near-surface. SEMis one of the most widely used analytical tools due to the extremelydetailed images it can provide. Coupled to an auxiliary EnergyDispersive X-ray Spectroscopy (EDS) detector, SEM also offers elementalidentification for nearly the entire periodic table. In one embodimentof the invention, SEM/EDS screens raw and final materials for gross sizeand morphological particle analysis as well as a confirmation ofelemental surface analysis of both our raw and processed materials. Inone embodiment of the invention, SEM and/or EDS is another acceptancecriterion of the invention in which the range of crystal sizes and/orelemental constituency is confirmed.

Cathodoluminescence is a technique that detects light emissions based onthe specific chemistry of a crystalline lattice structure.Cathodoluminescence accelerates and collimates an electron beam toward amaterial (e.g., a phosphorous material). When the incident beam impactsthe material, it causes the creation of secondary electrons and holeformation, the recombination of which leads to the emission of photonswhich are detected by a photospectrometer placed in close proximity tothe material.

In one embodiment of the invention, a representative phosphor containedin the novel phosphor-containing drug activator would be tested byplacing 10 mg inside a high vacuum chamber. The electron beam would beaccelerated using a bias voltage of 1000V to 1500V. Obtaining at least5000 counts (au) ensures that the material is emitting properly, andforms another acceptance criterion of the invention. Referencecathodoluminescence data for raw material phosphors are illustrated inFIGS. 2-5. FIG. 2 is a depiction of cathodoluminescence data forZn₂SiO₄:Mn²⁺ measured between 100-400 nm. FIG. 3 is a depiction ofcathodoluminescence data for Zn₂SiO₄:Mn²⁺ measured between 450-700 nm.FIG. 4 is a depiction of cathodoluminescence data for (3Ca₃(PO₄)₂.Ca(F,Cl)₂: Sb³⁺, Mn²⁺) measured between 100-400 nm. FIG. 5 is a depiction ofcathodoluminescence data for (3Ca₃(PO₄)₂.Ca(F, Cl)₂: Sb³⁺, Mn²⁺)measured between 450-700 nm. In one embodiment of the invention, thecathodoluminescence emission wavelength of UV and visible light emittedform an acceptance criterion of the invention.

The above described analytical testing is performed on purchasedphosphors before these materials are accepted for use in manufacturingof the novel phosphor-containing drug activator. The test methods forthe acceptance of the various raw materials in a preferred embodimentare specified below in Table 3.

TABLE 3 Acceptance Criteria for Raw Materials Parameter Method Phosphorcrystalline phase XRD Surface elemental composition XPS Core elementalcomposition ICP Emission CL Size distribution SEM

As further shown in FIG. 1B, in one embodiment of the invention,manufacturing of the novel phosphor-containing drug activator startsprocessing of the qualified raw phosphor materials by washing of thephosphor materials. More specifically, in one example, the phosphormaterials are individually weighed with one gram (1 g) of phosphorplaced in 50 mL plastic test tubes. Six mL of acetone are added andvortexed to thoroughly mix with the phosphors. The phosphors arepelletized via a low speed centrifuge, after which the excess acetone isremoved. This cycle is repeated an additional two times for each of thetwo phosphors.

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator then coats each of the two phosphorsfirst with ethyl cellulose, followed by a second coating consisting ofdiamond like carbon. Each of the phosphors constituting the phosphorcontaining device in one embodiment of the invention is independentlydoubly coated, before mixing the two phosphors together. FIG. 6 is anillustration of both phosphors (NP-200: Zn₂SiO₄:Mn²⁺ and GTP-4300:(3Ca₃(PO₄)₂.Ca(F, Cl)₂: Sb³⁺, Mn²⁺) coated with a first coating(Ethyl-Cellulose) and a second coating (Diamond-Like-Carbon).

For the ethyl-cellulose coating, in one preferred embodiment of theinvention, the phosphor particles are encapsulated based on theparameters provided in Table 4.

TABLE 4 Preferred thickness of the EC coating Ethyl Cellulose CoatingTarget Thickness (nanometers) 30 Phosphor Density (g/cc) 7.5

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator in one embodiment of the inventionthen coats each of the two phosphors with a secondary coat of DLC byPhysical Vapor Deposition to further encapsulate the phosphors and tofurther enhance their biocompatibility.

For the DLC film, a preferred thickness is 100 nm+/−3 nm, and apreferred Elastic Modulus is 45-55 Gpa, most preferably 50-53 Gpa.

The PVD coating machine is equipped with various process control sensorsand interlocks to ensure reproducibility.

The contact angle of non-coated glass and non-coated silicon are 19degrees and 65 degrees respectively. After the coating process, thecontact angles are preferably 100°+/−10%. The contact angle (for a waterdroplet) of both substrates is targeted to be between 90 and 110°. Thewater droplet contact angle provides another acceptance criterion of theinvention.

Specific release specifications for in-process testing are specified inthe table below:

TABLE 7 Release Specifications for In-Process Test Material ParameterMethod Coating thickness Step Height Size distribution Scanning Surfaceelemental composition XPS

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator in one embodiment of the inventioncontinues by mixing the two types of coated phosphors. Thephosphor-containing drug activator as noted above is made of acombination of two phosphors. Specifically, NP-200 (Zn₂SiO4:Mn²⁺) ismixed with (3Ca3(PO4)2.Ca(F, Cl)2: Sb3+, Mn2+) at a ratio NP-200:GTP-4300 of from 1:10 to 10:1, or from 1:5 to 5:1, or from 1:2 to 2:1,or about 1:2.

FIG. 7 is a representative illustration of the mixture of phosphorsconstituting the phosphor-containing device. (The efficacy of thismixture has been determined in vitro by assessing the cell kill broughtabout by the addition of the drug alone, mixture of phosphors alone, andthen the mixture of drug and phosphors under X-Ray energy.)

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator in one embodiment of the inventioncontinues by packaging of the combination phosphor-containing device.Specifically, the phosphor-containing drug activator is asepticallypre-weighed and packaged in sterile, nonpyrogenic 10 mL borosilicateamber glass vials. These vials come equipped with a 20 mm crimp neck,fitted with a 20 mm butyl rubber stopper and finally crimp sealed with20 mm flip-top aluminum seals. The final amount of device per sterilecontainer is specified by a kit number.

In one embodiment of the invention, multiple treatment kits can beprepared to accommodate different tumor sizes, with each vial designedfor example to deliver 0.6 mg of phosphors per cubic centimeter of tumorvolume.

Specifics of the container closure system are listed below in, althoughother sterile enclosure systems or enclosure systems that can besterilized are suitable for this invention.

TABLE 8A Container Closure Components Item Description/Name Manufacturer10 mL amber glass vials, 20 Wheaton 20 mm butyl rubber stopper Wheaton20 mm aluminum flip cap Wheaton

All device vials are cleaned and depyrogenated by the manufactureraccording to standardized procedures. After filling the vials with thephosphor-containing drug activator device, vials are stoppered with thebutyl rubber septum top. The stoppered vials are then crimp sealedemploying a flip-off seal and sent for sterilization.

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator in one embodiment of the inventioncontinues by sterilizing the vials. Specifically, crimp sealed vials areautoclaved for 30 minutes (dry-cycle, 250° F. at 14 PSI) and immediatelyremoved from the autoclave. Sterile vials are visually inspected andaffixed with an adhesive label (heat resistant, permanent ink) thatspecifies contents, packaging lot number and date of preparation.Labeled vials are then placed in labeled boxes fitted with individualvial partitions. Sealed cases of devices are labeled with a lot numberand shipped. FIG. 8 is a photographic depiction of on example of final,packaged device kit according to one embodiment of the invention inwhich the device kit includes the novel phosphor-containing devicesdescribed above.

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator in one embodiment of the inventioncontinues by device storage. The sterile materials of the novelphosphor-containing drug activator should be kept at room temperature(20-30° C.) in a humidity controlled environment. Dark storage ispreferred but not required.

As further shown in FIG. 1B, manufacturing of the novelphosphor-containing drug activator continues to steps ensuring qualitycontrol and retention of the characteristics noted above corroborated byanalytical testing before product release. Table 8B below shows alisting of acceptance criteria for the novel phosphor-containing drugactivator prior to the phosphor-containing drug activators being mixedwith a pharmaceutically acceptable carrier and/or UVADEX.

TABLE 8B Acceptance Criteria for the Phosphor-Containing DevicesParameter Method Size SEM Emissions Cathodoluminescence Coating XPSBiocompatibility Chemical extraction and toxicological risk assessmentper ISO 10993-17 Cytotoxicity: 10993-5 Sensitization: 10993-10Irritation: 10993-10 Systemic toxicity: 10993-11 Implantation: 10993-6Pyrogenicity USP 34 <151> Sterility USP <71> Bacterial Endotoxin USP<85>

United States Pharmacopeia (USP) is a compendium of quality controltests for drugs and excipients to be introduced into a medicinalformulation. It is published every year by the United StatesPharmacopoeial Convention.

In one embodiment of the invention, preparation of the vials will beperformed under USP 797 guidelines for compounding sterile preparations.Specifically, using a sterile syringe and 18-20 Ga needle, the novelphosphor-containing drug activator will be hydrated with a specifiedvolume of sterile UVADEX (psoralen). The contents of the vial will bevortexed for a minimum of 3 minutes to ensure proper phosphordispersion, after which the contents of the vial will be transferredinto a standard syringe. The treatment administration syringe will belabeled, at a minimum, with the following information: Subject name,subject number, device name, eIRB #, dose due date and time, pharmacistinitials. Immediately following preparation, the device preparation willbe delivered to the treatment area for administration to the subject.

In one embodiment of the invention, multiple treatment kits can beprepared to accommodate different tumor sizes, with each vial designedto deliver a consistent mass of phosphors per cubic centimeter of tumorvolume. Specifically, five (5) treatment kits can be prepared inaccordance with Table 9 below.

TABLE 9 Kit Packaging- Device Weight Per Kit Treat- Tumor Volume UVADEXFinal Total ment (cubic Hydration (mg/mL) Phosphor Group centimeters)Volume (mL) Phosphor (mg/sterile vial) TG-1 <15 0.75 10 7.5 TG-2 15.1−1.5 10 15.0 TG-3 30.0− 3 10 30.1 TG-4 50.0− 4 10 40.1 TG-5 >75 5 10 50.2

Device Administration and Activation

In conjunction with the pre-planned Monte Carlo derived x-ray exposures(or independent of the pre-planned Monte Carlo derived x-ray exposures),administration in one embodiment of the invention is preferably byintratumoral injection immediately prior to irradiation, at a totalvolume 0.033-0.067 mL per cm³ tumor, including 0.33 to 0.667 mg phosphorper cm³ tumor. In one embodiment of the invention, thephosphor-containing drug activator including the UVADEX will beadministered in multiple injections across the tumor.

In one embodiment of the invention, immediately after injection, thephosphor-containing drug activator will be activated with a low doseX-ray from an on-board imaging (OBI) system of the treatment linearaccelerator. The prescribed dose can be 0.6 to 1.0 Gy per fraction, andpreferably is set by the pre-planned Monte Carlo derived x-rayexposures.

In one embodiment of the invention, the radiation delivery is set suchthat 1 Gy of radiation is delivered per fraction using 80 kVp X-raysfrom the OBI on the linac CT. In one embodiment of the invention,immediately following intratumoral injection, the region of interestwill be exposed to a low dose kilovoltage radiation, by acquiring a conebeam CT (CBCT). At least one rotational kilovoltage CBCT can be utilizedsuch that images can be stored for future evaluation. Subsequent CBCT'scan be shared if there has been a significant reduction in tumor volumesuch that RT re-planning is necessary to avoid overdosing normal tissuesadjacent to the tumor.

In one embodiment of the invention, activation of thephosphor-containing drug activator can be performed using 1.0 Gy of80-100 kVp of x-ray energy delivered from a CT device. Accordingly, thein vivo phosphor-containing drug activator in one embodiment absorbs lowenergy x-rays from commercially available, FDA-cleared CT scanners andre-emits that energy in wavelengths that overlap with the absorptionspectra of UVADEX, an FDA approved drug that promotes apoptosis oftumors cells by for example forming photoadducts with DNA, resulting ininhibition of DNA synthesis and cell division.

As noted above, the Monte Carlo derived x-ray exposures in oneembodiment of the invention permit the settings of the x-ray source andits dose energy and dose flux to be optimized for the location anddistribution of the tumor (or diseased site) within the body.

Murine Studies

A baseline study has demonstrated the efficacy of x-ray activatedtreatments. In this study, a trial was conducted for an evaluation oftreatment administered to syngeneic 4T1-HER2 tumors grown on BALB/cmice. There were 4 arms of this trial: (1) saline only (control), (2)phosphors alone with x-ray, (3) psoralen (AMT) alone with x-ray, and (4)full treatment including both phosphor and psoralen and x-rayirradiation. Treatments were given in 3 fractions per week, to a totalof 6 fractions. In arms 2-3 a consistent x-ray irradiation technique wasused (0.36 Gy delivered at 75 kVp by 30 mA in 3 minutes) with 100 μg ofphosphor, and 5 μM psoralen (AMT). 0.5 Million 4T1-HER2 cells wereinjected subcutaneously to the right thigh of each mouse. There were 6-8mice per arm, and the study was repeated a second time, yieldingeffective sample sizes of 12-16.

The results from the in-vivo treatment of BALBC mice with syngeneic4T1-HER2 tumors are shown in FIGS. 9A-9D.

The toxicity of the treatment was evaluated by the monitoring of theaverage body weight for different arms of the treatment, as shown inFIG. 9A. There was no significant loss in body weight for any of thearms. Meanwhile, the data in FIGS. 9B and 9C show the suppression oftumor growth as compared to a saline injection.

In FIG. 9D-1, the overall saline controls are indicated by line (1). Thetwo other component control arms correspond to 5 μM psoralen (AMT) only,and 100 μg of phosphor only and are shown as lines (2) and (3),respectively. A consistent x-ray irradiation technique was used for allarms (except saline control) which was 0.36 Gy delivered at 75 kVp by 30mA in 3 minutes. (The full treatment, consisting of the device, drug andX-ray, is depicted as x-ray psoralen activated cancer therapy X-PACT,indicated by line (4).)

The first treatment was delivered to the syngeneic 4T1-HER2 tumors, onday 10 after implantation of the 4T1-HER2 tumors. Over the next twoweeks a growth delay was observed in the treatment arm, compared tocontrols. Encouragingly, by day 25, there was a 42% reduction in tumorvolume (p=0.0002). FIG. 9D-2 shows a photographic depiction showing acomparison of the tumors from different mice at different times afterexposure of the mice to different arms of the treatment.

In Vitro Studies

Also as part of the baseline study which demonstrated the efficacy ofx-ray activated treatments, in-vitro studies were conducted on a 4T1(murine breast cancer) cells incubated in appropriate growing media andbuffers before being trypsinized and plated evenly onto twelve (12) wellplates for 24 hours. About 20 minutes prior to irradiation, the wells ofeach plate were exposed to the following combinations of additives: (1)Control—cells only with no additives, (2) UVADEX only, (3) phosphorsonly, (4) UVADEX+ phosphors. Each plate had twelve (12) wells with threewells for each of the four treatment arms. The plates were thenirradiated with x-rays by placing the plate at a known distance from thex-ray source (e.g., 50 cm). After irradiation, the cells were incubatedon the plate for 48 hours prior to performing flow cytometry. GuavaAnnexinV flow cell cytometry was used to quantify cytotoxicity. The livecells were quantified, and the numbers of cells undergoing early or lateapoptosis were measured. The treatment was then contrasted using afigure of merit referred to as the fractional cell kill (or the % ofcells that were no longer viable). Table 10 shows this figure of meritfor different ratios. The final amount of phosphor used in each case waskept at 50 micro-grams. The mixture of phosphors consisting of a 1:2ratio by weight leads to better fractional cell kill. However, theresults showed the efficacy of the present invention over a wide rangeof ratios and when using only one or the other of the phosphors notedabove.

TABLE 10 Fractional Cell Kill with Different Phosphor Ratios NP-200GTP-4300 NP-200/GTP-4300 Fractional Kill 100%  0% 1:0 4.70%  33%  67%1:2 25.10%  0% 100% 0:1 13.30%

X-Ray Activation of the Phosphor-Containing Drug Activator

In one embodiment of the invention, the initiation energy that is usedto activate the phosphor device is delivered through a series of x-raypulses consisting of a programmable kV, a set distance from the source,an amperage, and a time. These parameters preferably being determined byMonte Carlo simulations (as detailed below). For the baseline study, thepreferred setting for x-ray pulsing that activates UVADEX in thepresence of phosphors consists of a distance of 50 cm, 80 kV, 200 mA and800 ms. In one embodiment of the invention, each of these pulses can berepeated a number of times to achieve the desired pre-planned MonteCarlo simulated dose. To obtain a dose of 1 Gy, twenty one (21) suchpulses for example could be used. The time between these programmablepulses could be set at 10 sec. It was found in the baseline study andthus expected for the Monte Carlo derived x-ray exposures of the presentinvention that the process is stable and that small variations in any ofthe settings do not lead to drastic changes in the results.

FIG. 10 is a summary of the fractional cell kill from the baseline studywhich demonstrated the efficacy of x-ray activated treatments. FIG. 10illustrates that the best results were obtained at 80 kV, 800 ms for afixed amperage of 200 mA.

Methylene blue staining of viable 4T1-HER2 cells confirms that thedevice works well according to the target parameters identified above. Aplate having six (6) wells is subjected to treatment. FIG. 11 is aphotographic depiction showing of Methylene Blue stain for cellviability post treatment with X-ray, phosphors and UVADEX from thebaseline study which demonstrated the efficacy of x-ray activatedtreatments. One well (#1) is the control. One well (#2) has phosphorcoated with EC and DLC (H100). One well (#3) has phosphor coated with EC(but no DLC). One well (#4) has drug UVADEX but no phosphors. One well(#5) has drug UVADEX and phosphors coated with EC and DLC. One well (#6)has drug UVADEX and phosphors coated with EC and no DLC.

All wells were exposed to the x-ray conditions noted above. Thecombinatory effect of drug plus phosphors is evident and leads to celldeath more effectively than the other conditions. The EC coatedphosphors and the EC and DLC coated phosphors both work effectively. Oneadded benefit to a dual coating is redundancy in safety of thetreatment.

In the baseline study which demonstrated the efficacy of x-ray activatedtreatments and applicable here for the Monte Carlo derived x-rayexposures of the present invention, the elapsed time between the variousx-ray pulses was considered as a variable. The x-ray pulses were in thebaseline study delivered using 5.3 seconds cycles between pulses. Thesetests were compared to cycles of 10 sec and 20 seconds between cycles.FIG. 12 is a plot showing the optimum cycle time between pulses from thebaseline study. The cycle time that best optimizes the fractional cellkill is 10 sec between pulses. So, in effect, a dose of 1 Gy isdelivered using twenty one (21) X-Ray pulses spaced apart by 10 seconds;and, each x-ray pulse consists of the following settings: 80 kV, 800 ms,200 mA. These were the settings used in the follow on canine in-vivostudies and applicable for the Monte Carlo derived x-ray exposures ofthe present invention.

Quantification of Cytotoxicity and Apoptosis

In the baseline study which demonstrated the efficacy of x-ray activatedtreatments, Guava Annexin V flow cell cytometry was used to quantifycytotoxicity in 3 murine tumor cell lines (mammary-4T1; 4T1-HER2, 4T1stably transfected with the human HER2 oncogene; glioma-CT2A; sarcomaKP-B). The mouse breast cancer cell line 4T1 was purchased from ATCC.4T1-HER2 was provided by Dr. Michael Kershaw (Cancer Immunology Program,Peter MacCallum Cancer Centre, Victoria, Australia) and maintained inDMEM with penicillin/streptomycin and 10% FBS The Sarcoma KP-B celllines were derived from primary tumors LSL-Kras; p53 Flox/Flox mice(45).

Tumors between 250 and 300 cm³ were digested using a mixture ofcollagenase/dispase/trypsin for 1 hour, passed through a 70-micronfilter, and cultured 5 to 8 passages before being used for experiments.Cells were cultured in DMEM medium supplemented with 10% FBS andincubated at 37° C. with 5% CO₂ in a humidified cell-culture incubator.

As part of the baseline study, in-vitro studies were conducted on platedcells following standard procedures. Cells were maintained in RPMI-1640supplemented with 10% fetal bovine serum and L-glutamine from GIBCO(Grand Island, N.Y.) growing in a humidified atmosphere of 5% CO₂. Afterincubation, cells were trypsinized and plated evenly onto twelve 12-wellplates for 24 hours. About 20 minutes prior to irradiation, the 12 wellsof each plate were exposed to the following combinations of additives:(1) control—cells only with no additives, (2) UVADEX only, (3) phosphorsonly, (4) UVADEX+ phosphors. Each plate had 12 wells with three wellsfor each of the four treatment arms. The plates were then irradiatedwith x-rays by placing the plate at a known distance from the x-raysource (50 cm). After irradiation, the cells were incubated on the platefor 48 hours prior to performing flow cytometry. For compatibility with96-well Guava Nexin® assay, the remaining cells were again trypsinized(after the 48 hour incubation) and plated onto the 96-well plate.

As part of the baseline study, a range of x-ray activation protocolswere investigated to determine the cytotoxic efficacy in relation tox-ray energy (kVp), total dose, and dose-rate. kV beam energies rangingbetween 80-100 kVp were investigated. kV beams were obtained fromvarious x-ray generating equipment, including orthovoltage units,standard diagnostic radiographic, fluoroscopic, and cone-beam computedtomography (CBCT) systems. The primary kV x-ray source utilized in thein vitro studies (for all data presented, unless stated otherwise in thefigure caption) was a Varian on-board-imaging x-ray source commonlyfound on Varian medical linear accelerators. The x-ray dose deliveredfor the in-vitro irradiations studied here ranged from 0.2-2 Gy, withmain emphasis on lower doses of 0.5-1 Gy.

As part of the baseline study, for x-ray irradiation, the well plateswere positioned at a set distance (typically 50 cm) from the x-raysource on a solid water phantom and the position of the well plateswithin the x-ray beam was verified by low dose kV imaging. Irradiationswere typically delivered in a “radiograph” mode; where multiple pulsesof a set mA (typically 200) and ms (typically 800) and pulses weredelivered every 5-15 seconds. In experiments investigating dose-rateeffects, the radiation was also delivered in a “pulsed fluoroscopy mode”(10 Hz) at the maximum mA setting. The most common kVp settings were 80and 100 kVp with no added filtration in the beam (Half Value Layer=3.0and 3.7 mm Al, respectively).

Two primary flow cytometry analyses were used, both determined at 48hours after treatment. Cells plated in 12-well plates, where individualwells in each plate received different experimental conditions (e.g.psoralen concentration), but the same x-ray dose (i.e. all wells in agiven plate receive the same x-ray dose). The first analysis evaluatedwas metabolic cell viability (herein referred to as cell viability)calculated from the number of whole cells per well as determined usingforward scattering (FSC). For each well, cell viability was normalizedto that in a control well without psoralen or phosphors but which didreceive radiation. (All wells on a given plate receive the same dose.)The second assay is Annexin V positivity, which is the fraction ofviable cells that are Annexin V+ by flow cell cytometry. The Annexin V(+) signal was corrected by subtracting the control signal from theno-psoralen/phosphor well on the same plate.

Other assays were used to provide independent complimentary informationon cell viability, e.g. Methylene blue staining and ATP-inducedLuminescence imaging (Cell-Titer-Glo® Luminescence Cell ViabilityAssay). The luminescence imaging permitted investigation of thecytotoxicity of psoralen activated directly with a UV lamp, and in theabsence of phosphors and x-ray radiation.

As part of the baseline study, several statistical analyses werecompleted, including unequal variance two-sample t-tests, Analysis ofVariance (ANOVA), and multi-variable regression. The unequal variancetwo-sample t-test tests the null hypothesis that the means ofobservations (e.g. viable cells, Annexin V signal) in two differentpopulations are equal. The p-value gives the probability that theobserved difference occurred by chance. Multi-variable regression wasused to test the null hypothesis that psoralen and phosphor had noeffect on Annexin V (+) signal and to test if there is a first-orderinteraction between the two therapeutic elements. Non-parametricstatistical analysis were also performed for each test, and showedconsistent results.

Results of statistical analyses are classified in four categories:weakly significant, moderately significant, significant, and verysignificant. A single asterisk indicates weakly significant statistics(*), where the p-value is in the range 0.01<p<0.05. Double asterisksindicate moderately significant statistics (**), where 0.001<p<0.01.Triple asterisks indicate significant statistics (***), where0.0001<p<0.001. Quadruple asterisks indicate very significant statistics(****), where p<0.0001. This convention will be used throughout theResults and Discussion section.

FIGS. 13A-13D illustrates the efficacy of treatment in-vitro in 4T1-HER2cells, utilizing a regimen of 1/10-diluted UVADEX (with equivalent of 10uM 8-MOP), 50 μg/mL phosphor 1 Gy of 80 kVp x-rays. FIG. 13A presentsthe cell viability data for three treatment conditions: UVADEX alone,phosphors alone, and the combination of UVADEX and phosphors. These datawere compiled from experiments performed on 5 different days (within 1month), including 15 separate experimental and 10 control plateirradiations. FIG. 13B presents the Annexin V (+) signal for the same 3conditions as FIG. 13A. FIGS. 13C and 13D show corresponding images ofviable cell populations revealed by methylene blue staining. Two resultsfrom two separate plates are shown, each with identical preparations toinvestigate reproducibility. Three concentrations of phosphor (25, 50,and 100 μg/mL) were tested with the UVADEX concentration fixed at 1/10dilution (10 uM 8-MOP). The anti-tumor effect is evident from this data.In FIGS. 13A-13D, the anti-tumor effects of the treatment and itsindividual components on 4T1-HER2 cells. In FIG. 13A, cell viabilityafter treatment (10 μM 8-MOP equivalent dilution of UVADEX, 50 μg/mLphosphor, 1 Gy of 80 kVp radiation) as determined by Guava flow cytomecytometry is depicted. N is the number of independent measurements(different days), and error bars indicate one standard deviation. InFIG. 13B, the Annexin V (+) fraction of viable cells shown in 13A. InFIGS. 13C and 13D, cell viability illustrated by methyl blue stainingfor identical plates each receiving 1 Gy of 80 kVp x-rays is depicted.Each plate contained wells including no additives (control), threeconcentrations of phosphor only (25, 50, and 100 μg/mL with DLC), UVADEXonly (10 uM 8-MOP equivalent dilution), and three combination treatmentregimes

In the baseline study which demonstrated the efficacy of x-ray activatedtreatments and applicable here for the Monte Carlo derived x-rayexposures of the present invention, the relative effectiveness of UVactivated psoralen on the three independent cell lines noted above isshown in FIGS. 14A and 14B. FIG. 14A shows comparable sensitivity ofCT2A (murine malignant glioma), 4T1 and KP-B (sarcoma) cell lines topsoralen activated by the phosphor device. FIG. 14B presents data onCT2A malignant glioma cells, for a range of treatment parametersincluding variable x-ray dose (0, 0.67 and 1 Gy), phosphor concentration(50 or 100 μg) and psoralen concentration (8-MOP) at 10, 20 and 40 μMrespectively. For FIG. 14A, x-ray induced UV light activated psoralenwas observed to reduce viable cells in 3 cell lines (data fromCell-Titer-Glo® Luminescence Cell Viability Assay under x-ray induced UVlight). N=4 for each cell line at each UV light condition (0, 0.25, 0.5,1.0 J/cm²). The psoralen concentration was 40 μM. For FIG. 14B, in CT2Acells, the treatment cytotoxicity increases with X-ray dose (0, 0.67 and1.00 Gy respectively), concentration of 8-MOP psoralen (10, 20 and 40 μMrespectively), and phosphor (50 and 100 μg/ml) respectively (p valuesshown thereon).

FIG. 15A presents a multi-variable linear regression analysis onthirty-six (36) independent measurements (wells) of Annexin V (+) as afunction of two variables: psoralen concentration, and phosphorconcentration. Psoralen and phosphor concentrations ranged from 10 μM to50 μM and 25 μg/mL to 200 μg/mL, respectively. Each of the 36 wells wasirradiated with 1 Gy of x-ray radiation at 80 kVp. The fit had thefollowing form given in Equation 1 (where P=phosphor, andConc=concentration):Annexin V(+)=A+B*[8-MOP Conc]+C*[P Conc]+D*[8-MOP Conc.]*[P Conc.]  Eq 1

For FIG. 15A, a multi-variable linear regression analysis on thirty-six(36) independent measurements of Annexin V (+) in 4T1-Her2 cells as afunction of psoralen and phosphor concentration. All samples received anx-ray dose of 1 Gy at 80 kVp. Psoralen and phosphor concentrationsranged from 10 μM to 50 μM and from 25 μg to 200 μg respectively. Thefitting equation is given at the top of the Table and in Equation 1. Theoverall fit was statistically significant as were each of the fitcoefficients. FIG. 15B shows a subset of data collected whichdemonstrate the magnitudes and effects of increasing concentrations ofpsoralen and phosphor on Annexin V (+) staining. For FIG. 15B, a subsetof the data that was collected on a single day, indicating magnitude andtrends. Neat UVADEX (100 μM 8-MOP) was diluted to 10, 20, and 50 μM, or1:10, 1:5, and 1:2 UVADEX. Four repeats (N=4) were performed for thecondition with 50 μg/mL of phosphor and 10 μM of 8-MOP diluted fromUVADEX.

FIG. 16 compares the use of the phosphor-containing drug activator attwo different x-ray energies (80 and 100 kVp), used in the baselinestudy and applicable here for the Monte Carlo derived x-ray exposures ofthe present invention. These experiments involved 4T1-HER2 cells treatedwith 10 μM 8-MOP equivalent UVADEX, and 50 μg/mL phosphors.Specifically, in FIG. 16, a treatment effect in 4T1-her2 was observed atboth 80 and 100 kVp, with suggestion that 80 kVp may be slightly moreeffective than 100 kVp (p=0.011, *). This data acquired from X-PACTtreatment of 4T1-HER2 cells with constant phosphor concentration of 50μg/mL and UVADEX diluted to 8-MOP concentration of 10 μM (1:10dilution). N is the number of independent measurements.

Discussion of Murine Studies

In the 4T1 in-vitro cell viability analysis (FIG. 13A), a substantialreduction in viable cells (˜48%, p<0.0001) was observed in the fulltreatment condition (phosphor device, psoralen, and x-ray). Cellviability was higher (70-85%) in the control conditions.

The effect of adding radiation to the control conditions did not lead toa reduction in cell viability. The addition of radiation to UVADEX alone(left bars in FIG. 13A) had no significant effect on cell viability(p=0.97). Cells exposed to phosphors alone (middle bars in FIG. 13A)show a slight reduction in cell viability (˜8%, p=0.034) when radiationwas added. The increased toxicity associated with the presence of bothphosphors and x-rays could be attributed to DNA damage arising by UVlight from x-ray induced phosphorescence from the phosphors. Substantialcytotoxicity (˜80%) was only observed in the full treatment arm,demonstrating the synergistic therapeutic effect of the combination ofphosphor, UVADEX and radiation.

In the 4T1 in-vitro apoptotic analysis (FIG. 13B), cells exposed toUVADEX alone (left bars) exhibited negligible apoptotic activity eitherwith or without x-ray (p values of 0.90 and 0.09 respectively). Therewas a slight increase in Annexin V staining when cells were exposed tophosphor alone (middle bars) (˜1%, p=0.098) suggesting a slight toxicityof the phosphors. However, it was only when both phosphor and UVADEXwere combined (right bars) that a statistically significant increase inAnnexin V staining was observed (˜8%, p<0.0001), indicating an increasein apoptosis. The anti-tumor effects of the treatment were furtherillustrated in the methyl blue staining in FIGS. 13C and 13D. In bothtreatments, little effect was observed for the individual components ofUVADEX and phosphor. The methyl blue staining results are consistentwith the flow cytometry data, in that all treatment components arerequired for high cytotoxicity. Less cytotoxicity is manifest in thefirst treatment condition because of decreased phosphor concentration.

When evaluated on the three different cell lines (FIG. 14A), an ANOVAanalyses reveals no statistically significant differences in thesensitivity of these lines either to individual components or to fulltreatment (p>0.05). This observation suggests that treatment may haveapplicability to a range of different tumor types. In CT2A malignantglioma cells, cell cytotoxicity was observed (FIG. 14B) to increase withthe magnitude of X-ray dose (0, 0.66 and 1 Gy respectively),concentration of 8-MOP psoralen (10, 20 and 40 μM respectively), andphosphor (50 and 100 μg/ml respectively). Two-sample unequal variancet-test analyses revealed that the effect of 1 Gy radiation wassignificant on CT2A cells for 20 μM 8-MOP+50 μg/mL phosphors and largerconcentrations, but was not significant below those concentrations,especially for the control group. This suggests that radiation itself isnot the cause of the increased cytotoxicity.

The most comprehensive in-vitro 4T1 analysis (FIG. 15A) revealed astatistically significant multi-variable linear regression (R2=0.72).The synergy interaction coefficient D was statistically significant(p<0.0001) and positive indicating an enhanced effect when phosphor andpsoralen were present. The interaction coefficients for psoralen andphosphor alone were only weakly suggestive (p˜0.1 and 0.05respectively). The p values indicate likely significance, but gave noindication of magnitude of effect, which is shown in FIG. 15B. A generalobservation from this data, acquired with constant x-ray dose, is thatapoptotic fraction induced by the treatment increases with eitherincreasing phosphor or psoralen concentration.

In FIG. 16, the in-vitro study investigated whether changing x-rayenergy had much effect on the treatment efficacy. This study indicatedthat ˜80 kVp would be optimal, but a higher energy would have anadvantage from treatment delivery perspective (greater penetration intissue). For this reason a 100 kVp beam energy was investigated. Anincrease in apoptotic signal (over the control) was observed fortreatments at both energies, indicating that both 80 and 100 kVp areapplicable for the Monte Carlo derived x-ray exposures of the presentinvention

Canine Study

As part of the baseline study, a study of spontaneous tumors in caninecompanion animals was conducted. The primary endpoint was device safety,with secondary endpoints to include treatment feasibility and tumorresponse. Each of six dogs was treated three times a week for threeconsecutive weeks. The treatment consisted of anesthetizing the dog,administering the phosphor-containing drug activator in a slurry ofUVADEX and delivering 0.6 to 1 Gy of 80 kVp x-ray energy from a conebeam CT system. Dogs were followed for one year post treatment.

The following protocols were utilized in the canine study and areapplicable for the Monte Carlo derived x-ray exposures of the presentinvention.

Protocol Summary: Without limiting the invention, the followingdescribes nine (9) repeated sessions including tumor measurements,visualizations, and treatments. (More or less than nine sessions can beused depending on the state of the malignancy. Indeed, a treatment with3-5 sessions might be useful in situations where the tumor is nearsurface and thorough exposure of the tumor is likely at each session.Alternatively, a treatment with 12-15 sessions might useful insituations where the tumor is within a human organ inside themusculoskeletal system exposure of the tumor is limited to the radiationexposure dose. Moreover, while described below with emphasis on caninetreatments, the invention is not limited to the use of these protocolsto canines as other animal and human patients could benefit.)

While other measurements, evaluations, and treatments for themalignancies can occur, each session typically included: tumormeasurements, toxicity scoring, labwork (collected-at treatments #2, 3,6 and 9), intratumoral injections of drug and energy modulatorsubstances (preferably while anesthetized), and radiation treatment (RT)with for example radiation of 1 Gy via 80 kVp X-rays. Following the ninesessions, there were follow-up weekly evaluations 3 and 6 weeks aftercompleting the last RT. The follow-up weekly evaluations a) evaluatedacute local and systemic toxicity via physical examination and routinelabwork, and b) estimated the tumor volume. Following the nine sessions,there were follow-up monthly evaluations at 3, 6, 9 and 12 months aftercompleting the last RT. The follow-up monthly evaluations a) evaluateddelayed local toxicity via physical examination, and b) describedduration of local tumor in enrolled cases.

Treatment and Imaging:

As noted above, subjects in the protocol were anesthetized nine (9)times over 3 weeks. The treatment included intratumoral injections of aslurry containing the novel phosphor-containing drug activator describedabove. During the radiation treatment, the tumor is imaged preferablyusing a cone-beam CT technology. The imaging may provide an indicationof the localization of phosphors and their distribution throughout thevolume of the tumor.

Intratumoral Injections:

-   -   1. 3-dimensional caliper measurements of the tumor.    -   2. Tumor volume will be estimated by multiplying the product of        3 orthogonal diameters by π/6.    -   3. The total volume to be injected into each tumor follows the        regiment outlined below using vials of sterilized phosphor to be        mixed UVADEX™ (100 μg/mL 8-MOP) as the sole diluent.

TABLE 11 mL of slurry milligrams of phosphor Total Tumor per cm³ tumorper cm³ of tumor volume volume Min Max Min Max injected 8-15 cubic 0.0340.063 0.333 0.625 0.5 mL   centimeters 15-29.9 cubic 0.033 0.067 0.3340.667 1 mL centimeters 30-49.9 cubic 0.040 0.067 0.401 0.67 2 mLcentimeters 50-74.9 cubic 0.040 0.060 0.401 0.600 3 mL centimeters75-99.9 cubic 0.040 0.053 0.400 0.533 4 mL centimeters >100 cubic 0.0440.050 0.435 0.500 5 mL centimeters

Especially for the canine treatments, but also for other patients, thefur/hair was clipped to improve visibility of the tumor. The tumor skinoverlying the tumor was prepared via three (3) alternating scrubs ofalcohol (or sterile saline) and chlorohexidine (or iodine).

A grid (e.g., of 1 cm squares) can optionally be used to ensuredistribution of the phosphor injections over the course of multipletreatments. Each week, typically, the center and corners can be marked(e.g., with a permanent or paint marker) in blue at the first of thatweek's treatments, green at the second treatment and white at the 3rdtreatment The grid can serve as a template for free-hand injection ofthe psoralen/phosphor slurry. The grid can be rotated (in the sameplane, pivoting about the center) 0.25 cm per day.

An appropriate amount of individual, coated phosphors were weighed intoa glass crimp top vial, fitted with a Teflon septum top and an aluminumcrimp ring, sealed via a crimp tool and autoclaved on a dry goods cycle(250° C., 30 minutes) and immediately removed from the autoclave,allowing to cool to room temperature. The sterilized materials werestored at room temperature, protected from light until use.

In one example, approximately 30 minutes prior to injection, sterilizedphosphors in sealed, crimp top vials were rehydrated with the indicatedvolume of UVADEX via a sterile needle through a septum cap. Postaddition of UVADEX, the entire mixture was continuously vortexed (usinga laboratory grade vortex mixer set to the highest setting) forapproximately 2 minutes. The mixed sample was introduced into a sterilesyringe and sealed with a luer lok cap. Syringes were delivered to thetreatment room and immediately prior to intratumoral injection, thesealed syringed was mixed via vortex for approximately 30 sec followedby injection into the desired subject site.

A 20-25 gauge sterile hypodermic needle was used to make free-handinjections in multiple injection sites across the tumor, or at thecorner of each square on the grid (if used). (Changing the size of theneedle or syringe can be used to optimize the injection distribution.)The total volume to be injected was divided evenly. Injections werepreferably made into palpable tumor, but not adjacent normal tissues.The plunger was depressed as the needle was withdrawn from the tumor, tomaximize the distribution of phosphors and UVADEX.

In one embodiment, tumors on or near the surface can be palpated tofacilitate delivery of the phosphors. Typically, multiple injections aremade to help distribute the phosphors throughout the tumor mass. Fordeeper treatment areas where the tumor cannot be palpated, ultrasoundguidance can be employed. Additionally, ultrasound can be used to assistin the dispersion of the UVADEX after the phosphors were delivered tothe treatment site.

This protocol used UVADEX (8-methoxypsoralen) as the activatablepharmaceutical agent (using concentrations in the range of 10 μg/mL to50 μg/ml), and used H100 (diamond coating formed in the presence of 40atomic % hydrogen) and EC (ethyl cellulose coating) with the combinationphosphor being a 1:2 mixture of NP200:GTP-4300.

Following injection of the phosphors and UVADEX, radiation therapyfollowed immediately.

Radiation Therapy:

0.6-1 Gy of radiation was delivered per treatment session using 80-100kVp X-rays from the on board imaging (OBI) device of a Novalis Txradiosurgery platform. (Besides the OBI device of a Varian linearaccelerator, a Trilogy, iX, TruBeam, etc. could be used with appropriateadjustment of x-ray dose and energy). With regard to the Novalis Txplatform, this platform includes three imaging modalities forpinpointing a tumor and positioning the patient with high precision. TheOBI may be programmed to provide continual imaging during treatment todetect movement and support robotic adjustments in patient positioningin six dimensions (although image quality during treatment will not beoptimum). The patient disposed on the Novalis Tx platform is positionedabove the concentric imaging position of the x-ray source at a distanceof 50 to 70 cm from the x-ray anode.

Subjects can be positioned on a linear accelerator's treatment couch(with the gantry at zero degrees) with the tumor centered at theisocenter of the linear accelerator (centering accomplished using visualinspection and lasers from the linear accelerator); the subject can thenbe vertically raised to a position with a source to surface distance(SSD) of 70-90 cm, per the optical distance indicator. This correspondsto a source to surface distance of 50-70 cm when the kilovoltage X-raysource (in the on-board imaging system) is moved to zero degrees forirradiation. Subjects with small body size are elevated on a riser whichsits atop the l linear accelerator's couch, to facilitate a terminal SSDof 50-70 cm; the goal is always to make the terminal SSD (from the kVsource) as close to 50 cm as possible, to minimize treatment times.

Immediately following the final intratumoral injection of the phosphordevice (preferably within several minutes) alignment radiation from thex-ray source (fluoroscopy and/or planar radiographs) confirmed that thesource was properly positioned to deliver x-rays to the tumor site byimaging of fiducial markers around the tumor. Then, within several or 5minutes of the final injection, x-rays from the 80 kVp source pulsingfor 800 microsecond pulses was delivered to the target site. In oneexample, the flux of x-rays was interrupted periodically and restarteduntil a dose of 0.5 to 1.0 Gy has been delivered in total. As anexample, multiple pulses can be used with each pulse is set for 80 kV,200 mA, 800 milliseconds. The total dose (in Gy) delivered wasdetermined by the number of pulses delivered. The number of pulsesdelivered to achieve the therapeutic dose was a function of the depthand location of the tumor. Bone mass in the exposure region preferablyis accounted. For example, a radiation therapy typically was designedfor a maximum estimated fractional bone dose of 3 Gy per fraction.

After, this therapeutic radiation treatment (preferably less than 30minutes, more preferably less than 20 minutes), the region of interestwas typically exposed to the kilovoltage radiation using the VarianNovalis OBI (on bard imaging system). At least one rotationalkilovoltage CBCT is typically scheduled such that images can be storedfor evaluation. Additional beam angles collimated per therecommendations can be used.

In the baseline study and applicable here for the Monte Carlo derivedx-ray exposures of the present invention, the preceding treatment in onepatient was further supplemented with a “booster” treatment, that is,the initial treatment considered a “priming treatment, with anadditional treatment used to “boost” the initial treatment response. A“booster treatment” in one embodiment could involve re-injecting thetumor with psoralen (or other photoactivatable drug) and radiating thetumor site again. A “booster treatment” in another embodiment couldinvolve re-injecting the tumor with psoralen (or other photoactivatabledrug) and an energy modulation agent and radiating the tumor site again.A “booster treatment” in another embodiment could involve radiating thetumor site again, but at a radiation level considered to be at either apalliative or therapeutic level. The purpose of these “booster”treatments is to activate the immune response initially or originallygenerated within the patient during the initial treatments.

In one embodiment of the booster treatment applicable here for the MonteCarlo derived x-ray exposures of the present invention, the phosphorconcentration can be increased to 20 mg/mL, the amount of UVADEX wasincreased 2-4 times, and the treatment frequency was increased to five(5) treatments in five (5) consecutive days. Furthermore, the timingbetween the prime (initial treatment sessions such as the ninetreatments described above) and the booster treatment was set to allowfor an initial humoral or cellular immune response, followed by a periodof homeostasis, most typically weeks or months after the initial primingtreatment.

Booster treatments in the present invention can include treatments whichnot only increase the drug or x-ray dose but can also in one embodimentdecrease the drug or x-ray dose over the original amount. In oneembodiment of the present invention, higher energy x-rays in 1 MV rangecan be used as the original treatment or as part of the boostertreatment. The higher energy range more uniformly exposes the tumor andmay create itself damaged cells to stimulate a patient's immune system.

From the baseline study, FIGS. 17A and 17B demonstrated a dramatic andcomplete response in one subject. The depicted pretreatment photograph(FIG. 17A) is directed to a rostral maxillary tumor with ahistopathologic diagnosis of a round cell tumor. The post treatmentphotograph (FIG. 17B) was taken three weeks after the completion oftreatment. This dog remains in complete response one year aftertreatment.

FIGS. 18A (pre-treatment) and 18B (post-treatment) depict anotherdramatic treatment effect. This subject had a maxillary plasma celltumor with disease progression after melphalan chemotherapy. This dogwas treated with the phosphor-containing drug activator and 8-MOP andhad stable disease thereafter. An additional “booster” treatment(consisting of 5 treatments in 5 consecutive days) was added, afterwhich the intra-oral part of the tumor completely resolved. Theinfra-oral component has remained stable for several months.

Variations of the Monte Carlo Derived X-Ray Exposure Treatments

In another embodiment of the invention, particularly for more aggressivecancers, an intervening treatment between the prime and boost stages canbe provided to stunt the growth of the tumor while the immune systemdevelops a response. The intervening treatment can take the form ofpalliative radiation, or other treatments known to those skilled in theart.

The invention can utilize one or more booster treatments in a mannersimilar to that described by David L. Woodland in their paper in TRENDSin Immunology Vol. 25 No. 2 Feb. 2004, entitled “Jump-Starting theImmune System: Prime-Boosting Comes of Age” (the entire contents ofwhich are incorporated herein by reference). The basic prime-booststrategy involves priming the immune system to a target antigen, or aplurality of antigens created by the drug and/or radiation induced cellkill, and then selectively boosting this immunity by re-exposing theantigen or plurality of antigens in the boost treatment. One keystrength of this strategy in the present invention is that greaterlevels of immunity are established by heterologous prime-boost than canbe attained by a single vaccine administration or homologous booststrategies. For example, the initial priming events elicited by a firstexposure to an antigen or a plurality of antigens appear to be imprintedon the immune system. This phenomenon is particularly strong in T cellsand is exploited in prime-boost strategies to selectively increase thenumbers of memory T cells specific for a shared antigen in the prime andboost vaccines. As described in the literature, these increased numbersof T cells ‘push’ the cellular immune response over certain thresholdsthat are required to fight specific pathogens or cells containing tumorspecific antigens. Furthermore, the general avidity of the boostedT-cell response is enhanced, which presumably increases the efficacy ofthe treatment.

Here, in this invention and without limitation as to the details butrather for the purpose of explanation, the initial treatment protocoldevelops antibodies or cellular immune responses to thepsoralen-modified or X-ray modified cancer cells. These “initial”responses can then be stimulated by the occurrence of a large number ofnewly created psoralen-modified or X-ray modified cancer cells. As such,the patient's immune system would mount a more robust response againstthe cancer than would be realized in a single treatment series.

In one embodiment of the invention, as noted above, the treatments forthe non-adherent or liquid tumors can be given once, or periodically(such as 3 to 5 times a week), or intermittently, such as 3 to 5 times aweek, followed by a period of no treatment, typically one to two weeks,followed by another treatment period of 3 to 5 times a week.

Additionally, a prime-boost strategy can be employed, such as isdescribed herein for the treatment of solid tumors. The prime phase canbe a single treatment, periodic treatment or intermittent treatment,followed by a period of no treatment, typically 6-12 weeks, followed bya booster treatment. The booster treatment can be the same duration andfrequency as the prime treatment, or can be accelerated or shortened.

In one embodiment of the invention, prior to the initial treatment orprior to booster treatments, the immune system of the subject could befurther stimulated by injection of a more conventional vaccine such asfor example a tetanus vaccine. Prior work by others has shown theefficacy of a tetanus booster to bolster the immune system's attack onthe tumor by helping cancer vaccines present in the subject migrate tothe lymph nodes, activating an immune response. Here, in this invention,the autovaccines generated internally from the treatments describedabove could also benefit from this effect.

The invention also has utility in treating non-adherent (liquid) tumors,such as lymphoma. Instead of injecting the phosphors and drug into thesolid tumor, the phosphor and drug combination can be injected into alymph node, preferably the draining lymph node distal to a lymphomatumor, or any lymph node with disease involvement. Alternatively,treating any area with a lymphoma infiltration is acceptable.

Debris from dead and dying tumor cells would be transported to regionallymph nodes where immune activation would occur and tumor specificimmune cells would then recirculate and begin to destroy tumor cells atmultiple sites. This killing of tumor cells in the lymph or any organwith a lymphoma infiltrate creates more immune stimuli for activation inthe regional lymph nodes and further re-circulation, making repeattreatments beneficial.

In one embodiment of the invention, intervening treatments to controlthe growth or spread of the lymphoma while the immune system activatescan also be added. These treatments can include palliative x-rayexposures, enzyme treatments such as asparginase, chemotherapy, orsurgery.

The typical tube voltage for radiography is typically in the range of60-120 kV. The x-ray beam is then passed through filtration achieved byinterposing various metal filters in the x-ray path. The metals that canbe used include Aluminum (Al) and Copper (Cu). The filtration of thebeam eliminates noise and results in a cleaner output beam,preferentially removing softer photons. This leads to a cleaner spectrumand systems from different vendors would result in having substantiallythe same output spectrum. After filtration the beam is passed through acollimator. X-ray radiation can be collimated into a fan-shaped beam.The beam is passed through an adjustable aperture. Lead (Pb) plates ofabout 2 mm in thickness can be used to block the beam and limit theexposure of x-ray to the tumor area.

The 60-120 kV beam can be sufficient to activate the bio-therapeuticagent via the phosphors described in the present invention.

In one embodiment, a method in accordance with the present inventionutilizes the principle of energy transfer to and among different agentsto control delivery and activation of cellular changes by irradiationsuch that delivery of the desired effect is more intensified, precise,and effective than the conventional techniques. The phosphors notedabove represent but one energy modulation agent of the presentinvention. In general, at least one energy modulation agent can beadministered to the subject which adsorbs, intensifies or modifies saidinitiation energy into an energy that effects a predetermined cellularchange in said target structure. The energy modulation agent may belocated around, on, or in said target structure. Further, the energymodulation agent can transform a photonic initiation energy into aphotonic energy that effects a predetermined change in said targetstructure. In one embodiment, the energy modulation agent decreases thewavelength of the photonic initiation energy (down convert). In anotherembodiment, the energy modulation agent can increase the wavelength ofthe photonic initiation energy (up convert). In a different embodimentthe modulation agent is one or more members selected from abiocompatible fluorescing metal nanoparticle, fluorescing metal oxidenanoparticle, fluorescing dye molecule, gold nanoparticle, silvernanoparticle, gold-coated silver nanoparticle, a water soluble quantumdot encapsulated by polyamidoamine dendrimers, a luciferase, abiocompatible phosphorescent molecule, a combined electromagnetic energyharvester molecule, and a lanthanide chelate exhibiting intenseluminescence.

In one aspect of the invention, a downconverting energy modulation agentcan comprise inorganic particulates selected from the group consistingof: metal oxides; metal sulfides; doped metal oxides; and mixed metalchalcogenides. In one aspect of the invention, the downconvertingmaterial can comprise at least one of Y₂O₃, Y₂O₂S, NaYF₄, NaYbF₄, YAG,YAP, Nd₂O₃, LaF₃, LaCl₃, La₂O₃, TiO₂, LuPO₄, YVO₄, YbF₃, YF₃, Na-dopedYbF₃, ZnS; ZnSe; MgS; CaS and alkali lead silicate includingcompositions of SiO₂, B₂O₃, Na₂O, K₂O, PbO, MgO, or Ag, and combinationsor alloys or layers thereof. In one aspect of the invention, thedownconverting material can include a dopant including at least one ofEr, Eu, Yb, Tm, Nd, Mn Tb, Ce, Y, U, Pr, La, Gd and other rare-earthspecies or a combination thereof. The dopant can be included at aconcentration of 0.01%-50% by mol concentration.

In one aspect of the invention, the downconverting energy modulationagent can comprise materials such as ZnSeS:Cu, Ag, Ce, Tb; CaS: Ce,Sm;La₂O₂S:Tb; Y₂O₂S:Tb; Gd₂O₂S:Pr, Ce, F; LaPO₄. In other aspects of theinvention, the downconverting material can comprise phosphors such asZnS:Ag and ZnS:Cu, Pb. In other aspects of the invention, thedownconverting material can be alloys of the ZnSeS family doped withother metals. For example, suitable materials include ZnSe_(x)S_(y):Cu,Ag, Ce, Tb, where the following x, y values and intermediate values areacceptable: x:y; respectively 0:1; 0.1:0.9; 0.2:0.8; 0.3:0.7; 0.4:0.6;0.5:0.5; 0.6:0.4; 0.7:0.3; 0.8:0.2; 0.9:0.1; and 1.0:0.0.

In other aspects of the invention, the downconverting energy modulationagent can be materials such as sodium yttrium fluoride (NaYF₄),lanthanum fluoride (LaF₃), lanthanum oxysulfide (La₂O₂S), yttriumoxysulfide (Y₂O₂S), yttrium fluoride (YF₃), yttrium gallate, yttriumaluminum garnet (YAG), gadolinium fluoride (GdF₃), barium yttriumfluoride (BaYF₅, BaY₂F₈), gadolinium oxysulfide (Gd₂O₂S), calciumtungstate (CaWO₄), yttrium oxide:terbium (Yt₂O₃Tb), gadoliniumoxysulphide:europium (Gd₂O₂S:Eu), lanthanum oxysulphide:europium(La₂O₂S:Eu), and gadolinium oxysulphide:promethium, cerium, fluorine(Gd₂O₂S:Pr,Ce,F), YPO₄:Nd, LaPO₄:Pr, (Ca,Mg)SO₄:Pb, YBO₃:Pr, Y₂SiO₅:Pr,Y₂Si₂O₇:Pr, SrLi₂SiO₄:Pr,Na, and CaLi₂SiO₄:Pr.

In other aspects of the invention, the downconverting energy modulationagent can be near-infrared (NIR) downconversion (DC) phosphors such asKSrPO₄:Eu²⁺Pr³⁺, or NaGdF₄:Eu or Zn₂SiO₄:Tb³⁺,Yb³⁺ or β-NaGdF₄ co-dopedwith Ce³⁺ and Tb³⁺ ions or Gd₂O₂S:Tm or BaYF₅:Eu³⁺ or other downconverters which emit NIR from visible or UV light exposure (as in acascade from x-ray to UV to NIR) or which emit NIR directly after x-rayor e-beam exposure.

In one aspect of the invention, an up converting energy modulation agentcan be at least one of Y₂O₃, Y₂O₂S, NaYF₄, NaYbF₄, YAG, YAP, Nd₂O₃,LaF₃, LaCl₃, La₂O₃, TiO₂, LuPO₄, YVO₄, YbF₃, YF₃, Na-doped YbF₃, or SiO₂or alloys or layers thereof.

In one aspect of the invention, the energy modulation agents can be usedsingly or in combination with other down converting or up convertingmaterials.

Below is a list of X-ray phosphors which can be used in the presentinvention along with their corresponding peak emission values.

TABLE 14 Emission Spectrum X-ray Absorption Microstructure Peak EmissionEmiss Eff K-edge Specific Crystal # Phosphor (nm) (%) Eff (Z) (keV)Gravity Structure Hygroscopic 1 BaFCl:Eu²⁺ 380 13 49.3 37.38 4.7Tetragonal N 2 BaSO₄ ⁻:Eu²⁺ 390 6 45.5 37.38 4.5 Rhombic N 3 LaOBr:Tm³⁺360, 460 14 49.3 38.92 6.3 Tetragonal N 4 YTaO₄ 337 59.8 67.42 7.5Monolithic N 5 YTaO₄:Nb 410 11 59.8 67.42 7.5 Monolithic N (*) 6 CaWO₄420 5 61.8 69.48 6.1 Tetragonal N 7 LaOBr:Tb³⁺ 420 20 49.3 38.92 6.3Tetragonal N 8 Y₂O₂S:Tb³⁺ 420 18 34.9 17.04 4.9 Hexgonal N 9 ZnS:Ag 45017 26.7 9.66 3.9 Hexgonal N 10 (Zn,Cd)S:Ag 530 19 38.4 9.66/26.7 4.8Hexgonal N 11 Gd₂O₂S:Tb³⁺ 545 13 59.5 50.22 7.3 Hexgonal N 12La₂O₂S:Tb³⁺ 545 12.5 52.6 38.92 6.5 Hexgonal NVarious plastic scintillators, plastic scintillator fibers and relatedmaterials are made of polyvinyltoluene or styrene and fluors. Thesematerials could be used in the present invention especially ifencapsulated or otherwise chemically isolated from the target structureso not as to be dissolved or otherwise deteriorated by the fluids of thetarget structure. These and other formulations are commerciallyavailable, such as from Saint Gobain Crystals, as BC-414, BC-420,BC-422, or BCF-10.

TABLE 15 Product Peak Emission Phosphor Reference (nm) Organic BC-414392 Organic BC-420 391 Organic BC-422 370Other polymers are able to emit in the visible range and these include:

TABLE 16 # of Phosphor Product Peak Emission Photons Per (Fiber Forms)Reference (nm) MeV Organic BCF-10 432 8000 Organic BC-420 435 8000Organic BC-422 492 8000

Table 17 shows a wide variety of energy modulation agents which can beused in this invention, which is provided as an exemplary list only andis not intended to be limiting of the energy modulation agents useablein the present invention.

TABLE 17 Emission X-Ray Spectrum Absorption Phosphor Peak EmissionK-edge Specific Crystal Color (nm) Emiss Eff (%) Eff (z) (keV) GravityStructure Hygroscopic Zn3(PO4)2:Tl+ 310 N BaF2 310 Slightly CsI 315 NCa3(PO4)2:Tl+ 330 N YTaO4 337 59.8 67.42 7.5 Monolithic N CsI:Na 338 YBaSi2O5:Pb2+ 350 N Borosilicate 350 N LaCl3(Ce) 350 Y SrB4O7F:Eu2+ 360 NRbBr:Tl+ 360 ? (Ba,Sr,Mg,)3Si207:Pb2+ 370 N YAlO3:Ce3+ 370 N BC-422 370Organic ? BaFCl:Eu2+ 380 13 49.3 37.38 4.7 Tetragonal N BaSO4−:Eu2+ 3906 45.5 37.38 4.5 Rhombic N BaFBr:Eu2+ 390 ? BC-420 391 Organic ? BC-414392 Organic ? SrMgP207:Eu2+ 394 N BaBr2:Eu2+ 400 N (Sr,Ba)Al2Si2O8:Eu2+400 N YTaO4:Nb(*) 410 11 59.8 67.42 7.5 Monolithic N Y2SiO5:Ce3+ 410 NCaWO4 420 5 61.8 69.48 6.1 Tetragonal N LaOBr:Tb3+ 420 20 49.3 38.92 6.3Tetragonal N Y2O2S:Tb3+ 420 18 34.9 17.04 4.9 Hexgonal N Lu2SiO5:Ce3+420 N Lu1.8Y0.2SiO5:Ce 420 N ZnS:Ag 450 17 26.7 9.66 3.9 Hexgonal NCdWO4 475 Slightly Bi4Ge3O12(BGO) 480 N (Zn,Cd)S:Ag 530 19 38.49.66/26.7 4.8 Hexgonal N Gd2O2S:Tb3+ 545 13 59.5 50.22 7.3 Hexgonal NLa2O2S:Tb3+ 545 12.5 52.6 38.92 6.5 Hexgonal N Y3Al5O12(Ce) 550 NLaOBr:Tm3+ 360, 460 14 49.3 38.92 6.3 Tetragonal N CaF2(Eu) 435/300 N

By selection of one or more of the phosphors noted above (or othersknown in the art), the present invention permits one to provide in avicinity of or within a target structure one or more light emitterscapable of emitting different wavelengths corresponding to respectivebiological responses, and permits the activation of one or morebiological responses in the target structure depending on at least oneor more different wavelengths of light generated internally or providedinternally within the subject, wherein the different wavelengthsactivate the respective biological responses (i.e., selectiveactivation).

Another embodiment to deliver the energy modulation agent-PA drugsinvolves the use of ferritin and apoferritin compounds. There isincreasing interest in ligand-receptor-mediated delivery systems due totheir non-immunogenic and site-specific targeting potential to theligand-specific bio-sites. Platinum anticancer drug have beenencapsulated in apoferritin. Ferritin, the principal iron storagemolecule in a wide variety of organisms, can also be used as a vehiclefor targeted drug delivery. It contains a hollow protein shell,apoferritin, which can contain up to its own weight of hydrous ferricoxide-phosphate as a microcrystalline micelle. The 24 subunits offerritin assemble automatically to form a hollow protein cage withinternal and external diameters of 8 and 12 nm, respectively. Eighthydrophilic channels of about 0.4 nm, formed at the intersections ofsubunits, penetrate the protein shell and lead to the protein cavity. Avariety of species such as gadolinium (Gd³⁺) contrast agents,desferrioxamine B, metal ions, and nanoparticles of iron salts can beaccommodated in the cage of apoferritin. Various metals such as iron,nickel, chromium and other materials have been incorporated intoapoferritin. Zinc selenide nanoparticles (ZnSe NPs) were synthesized inthe cavity of the cage-shaped protein apoferritin by designing a slowchemical reaction system, which employs tetraaminezinc ion andselenourea. The chemical synthesis of ZnSe NPs was realized in aspatially selective manner from an aqueous solution, and ZnSe cores wereformed in almost all apoferritin cavities with little bulkprecipitation.

Some of the phosphors used for psoralen activation have a high atomicmass with a high probability of interaction with the X-Ray photons. As aresult, the phosphors are also X-Ray contrasting agents. An image can bederived through X-Ray imaging and can be used to pin-point the locationof the tumor.

In a further embodiment, methods in accordance with the presentinvention may further include adding an additive to alleviate treatmentside-effects. Exemplary additives may include, but are not limited to,antioxidants, adjuvant, or combinations thereof. In one exemplaryembodiment, psoralen is used as the activatable pharmaceutical agent,UV-A is used as the activating energy, and antioxidants are added toreduce the unwanted side-effects of irradiation.

The activatable pharmaceutical agent and derivatives thereof as well asthe energy modulation agent, can be incorporated into pharmaceuticalcompositions suitable for administration. Such compositions typicallycomprise the activatable pharmaceutical agent and a pharmaceuticallyacceptable carrier. The pharmaceutical composition also comprises atleast one additive having a complementary therapeutic or diagnosticeffect, wherein the additive is one selected from an antioxidant, anadjuvant, or a combination thereof.

As used herein, “pharmaceutically acceptable carrier” is intended toinclude any and all solvents, dispersion media, coatings, antibacterialand antifungal agents, isotonic and absorption delaying agents, and thelike, compatible with pharmaceutical administration. The use of suchmedia and agents for pharmaceutically active substances is well known inthe art. Except insofar as any conventional media or agent isincompatible with the active compound, use thereof in the compositionsis contemplated. Supplementary active compounds can also be incorporatedinto the compositions. Modifications can be made to the compound of thepresent invention to affect solubility or clearance of the compound.These molecules may also be synthesized with D-amino acids to increaseresistance to enzymatic degradation. If necessary, the activatablepharmaceutical agent can be co-administered with a solubilizing agent,such as cyclodextran.

A pharmaceutical composition of the invention is formulated to becompatible with its intended route of administration. Examples of routesof administration include parenteral, e.g., intravenous, intradermal,subcutaneous, oral (e.g., inhalation), transdermal (topical),transmucosal, rectal administration, and direct injection into theaffected area, such as direct injection into a tumor. Solutions orsuspensions used for parenteral, intradermal, or subcutaneousapplication can include the following components: a sterile diluent suchas water for injection, saline solution, fixed oils, polyethyleneglycols, glycerin, propylene glycol or other synthetic solvents;antibacterial agents such as benzyl alcohol or methyl parabens;antioxidants such as ascorbic acid or sodium bisulfate; chelating agentssuch as ethylenediaminetetraacetic acid; buffers such as acetates,citrates or phosphates, and agents for the adjustment of tonicity suchas sodium chloride or dextrose. The pH can be adjusted with acids orbases, such as hydrochloric acid or sodium hydroxide. The parenteralpreparation can be enclosed in ampoules, disposable syringes or multipledose vials made of glass or plastic.

Pharmaceutical compositions suitable here for injectable use includesterile aqueous solutions (where water soluble) or dispersions andsterile powders for the extemporaneous preparation of sterile injectablesolutions or dispersion. For intravenous administration, suitablecarriers include physiological saline, bacteriostatic water, orphosphate buffered saline (PBS). In all cases, the composition must besterile and should be fluid to the extent that easy syringabilityexists. It must be stable under the conditions of manufacture andstorage and must be preserved against the contaminating action ofmicroorganisms such as bacteria and fungi. The carrier can be a solventor dispersion medium containing, for example, water, ethanol, polyol(for example, glycerol, propylene glycol, and liquid polyethyleneglycol, and the like), and suitable mixtures thereof. The properfluidity can be maintained, for example, by the use of a coating such aslecithin, by the maintenance of the required particle size in the caseof dispersion and by the use of surfactants. Prevention of the action ofmicroorganisms can be achieved by various antibacterial and antifungalagents, for example, parabens, chlorobutanol, phenol, ascorbic acid,thimerosal, and the like. In many cases, it will be preferable toinclude isotonic agents, for example, sugars, polyalcohols such asmanitol, sorbitol, sodium chloride in the composition. Prolongedabsorption of the injectable compositions can be brought about byincluding in the composition an agent which delays absorption, forexample, aluminum monostearate and gelatin.

Sterile injectable solutions can be prepared by incorporating the activecompound in the required amount in an appropriate solvent with one or acombination of ingredients enumerated above, as required, followed byfiltered sterilization. Generally, dispersions are prepared byincorporating the active compound into a sterile vehicle that contains abasic dispersion medium and the required other ingredients from thoseenumerated above. In the case of sterile powders for the preparation ofsterile injectable solutions, methods of preparation are vacuum dryingand freeze-drying that yields a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof.

In one embodiment, the active compounds (phosphors and UVADEX) areprepared with carriers that will protect the compound against rapidelimination from the body, such as a controlled release formulation,including implants and microencapsulated delivery systems.Biodegradable, biocompatible polymers can be used, such as ethylenevinyl acetate, polyanhydrides, polyglycolic acid, collagen,polyorthoesters, and polylactic acid. Methods for preparation of suchformulations will be apparent to those skilled in the art. The materialscan also be obtained commercially. Liposomal suspensions (includingliposomes targeted to infected cells with monoclonal antibodies to viralantigens) can also be used as pharmaceutically acceptable carriers.These can be prepared according to methods known to those skilled in theart, for example, as described in U.S. Pat. No. 4,522,811.

As shown above, the pharmaceutical compositions can be included in acontainer, pack, or dispenser together with instructions foradministration. The instructions could be in any desired form, includingbut not limited to, printed on a kit insert, printed on one or morecontainers, as well as electronically stored instructions provided on anelectronic storage medium, such as a computer readable storage medium.Also optionally included is a software package on a computer readablestorage medium that permits the user to integrate the information andcalculate a control dose, to calculate and control intensity of theirradiation source.

It will also be understood that the order of administering the differentagents is not particularly limited. Thus in some embodiments theactivatable pharmaceutical agent may be administered before thephosphors comprising the novel phosphor-containing drug activator, whilein other embodiments the phosphors may be administered prior to theactivatable pharmaceutical agent. It will be appreciated that differentcombinations of ordering may be advantageously employed depending onfactors such as the absorption rate of the agents, the localization andmolecular trafficking properties of the agents, and otherpharmacokinetics or pharmacodynamics considerations.

Monte Carlo Derived Treatments

In the past, Monte Carlo (MC) models have been developed to assist inmodeling mammographic imaging from different x-ray sources. Tzanakos etal. in the paper entitled A Monte Carlo simulation model of mammographicimaging with x-ray sources of finite dimensions, Phys Med Biol. 2002Mar. 21; 47(6):pp. 917-33, the entire contents of which are incorporatedby reference, describe a simulation model of mammographic x-ray sources.The model in that paper was based on MC methods and took into accountthe electron penetration inside the anode, the anode geometry andmaterial, as well as the spectral and spatial distribution of x-rays.The main outputs of that model were Monte Carlo generated images thatcorresponded to the irradiation of properly designed phantoms. In thisway, it was possible to study the influence of x-ray sourcecharacteristics prior to clinical studies.

One commercial MC based simulation tool is described in The FLUKA Code:An Accurate Simulation Tool for Particle Therapy, by Giuseppe Battistoniet al, Front. Oncol., 11 May 2016|http://dx.doi.org/10.3389/fonc.2016.00116, the entire contents of whichare incorporated herein by reference. As described therein, MCsimulations have been a tool for the design of clinical facilities,providing a detailed description of the beam line and the deliverysystem. In situations where experimental validation was unavailableand/or analytical methods were inadequate, MC simulation allowedpatient-specific dose calculations to be made.

In U.S. Pat. No. 6,148,272 (the entire contents of which areincorporated herein by reference), there is described a system andmethod for radiation dose calculation within sub-volumes of a MonteCarlo based particle transport grid. In a first step of the method voxelvolumes enclosing a first portion of the target mass are received. Asecond step in the method defines dosel volumes which enclose a secondportion of the target mass and overlap the first portion. A third stepin the method calculates common volumes between the dosel volumes andthe voxel volumes. A fourth step in the method identifies locations inthe target mass of energy deposits. And, a fifth step in the methodcalculates radiation doses received by the target mass within the doselvolumes. A common volume calculation module inputs voxel volumesenclosing a first portion of the target mass, inputs voxel massdensities corresponding to a density of the target mass within each ofthe voxel volumes, defines dosel volumes which enclose a second portionof the target mass and overlap the first portion, and calculates commonvolumes between the dosel volumes and the voxel volumes. A dosel massmodule, multiplies the common volumes by corresponding voxel massdensities to obtain incremental dosel masses, and adds the incrementaldosel masses corresponding to the dosel volumes to obtain dosel masses.A radiation transport module identifies locations in the target mass ofenergy deposits. A dose calculation module, coupled to the common volumecalculation module and the radiation transport module, for calculatingradiation doses received by the target mass within the dosel volumes.These dose calculation steps would be suitable in the present inventionfor calculation of the energy deposited at a diseased site to betreated.

Indeed, in one embodiment of the present invention, Monte Carlosimulations are used to simulate both the type of high energy x-raysource treating the patient and the x-ray dose absorbed in a patient'stumor region to be treated. In one embodiment of the invention, standardMC simulation tools are applied to model the x-ray source from acommercial x-ray machine. The x-ray source models are then compared tothe measured x-ray flux as determined by one or more sensors measuringthe distribution of xrays emitted from the x-ray source. Followingconfirmation or refinement of the x-ray source model, the Monte Carlosimulations are used to model the tumor treatment area of the patient.In one embodiment, a CT scan is first used to identify the distributionof bone tissue and soft issue in the neighborhood of the tumor. Fromthis distribution, the Monte Carlo simulations then use a firstprinciples calculation to determine where the x-rays (from thecommercial x-ray source) are absorbed respectively in the bone tissueand soft tissue regions. While described below with respect to x-rayexposure, the present invention is not so limited and the modeling ofother energy sources can be used, such as exposure of a patient toelectron beams, proton beams, ion beams, gamma rays, and beta rays.

In a further embodiment of the present invention, the Monte Carlosimulation can be used to determine a psoralen activation field within atumor, and use that determination to set the parameters of theirradiation source and configuration to generate that psoralenactivation field in-vivo within the patient.

FIG. 19 is a composite micrograph showing a canine cone-beam computedtomography (CBCT) image in different perspectives and a FlukaFlairsimulation of the radiation dose received in the canine.

In one aspect of the invention, the x-ray source (or high energy source)modeling and the x-ray penetration (or energy dose distribution)modeling include parameters such as the energy spectrum, the off-axisratio, the half value layer, the percent depth dose (PDD), andbackscatter factor (BSF) which are calculated and to the degree possiblemeasured as confirmation of the model. A material's half-value layer(HVL), or half-value thickness, is the thickness of the material atwhich the intensity of radiation entering it is reduced by one half. Theoff-axis ratio (OAR) is the ratio of off-axis dose to the central axisdose at the same depth. The backscattered factor (BSF) is used todetermine a true absorbed dose from the factors by which the radiationdose is increased by radiation scattered back from the body. Use of thebackscatter factor in calculations of the radiation dose accounts forthe radiation scattered backwards to the surface of the patient, whichlike the forward radiation will be absorbed.

Dosimetry Measurements for Model Verification:

FIG. 20A is a schematic depiction of the x-ray source geometry, and FIG.20B is a schematic depiction of a simulated 80 KVp x-ray energy spectrumemanating from the OBI device. The x-ray tube specifications includingtarget design, material composition, and density, and filtration systemswere obtained from the manufacturer (Varian Medical Systems, Palo AltoCalif.) and the manufacturer provided Monte Carlo Data Package for theOBI37. While the present invention is not limited to a particular x-rayspectrum or source, 80 kVp spectrum from an on-board imaging (OBI) on aVarian Trilogy linear accelerator (LINAC) is of interest. The modelssimulated generation of the 80 kVp spectrum. Specifically, FIG. 20Bdepicts the 80 kVp photon energy spectrum simulated from the x-raysource geometry detailed above, the simulation using 5×108 histories andan energy bin size of 0.25 keV.

For the 80 kVp setting, verification measurements included the beamquality defined using half value layer (HVL) in pure aluminum, percentdepth dose (PDD) curves, backscatter factors (B), collimator scatterfactor (Sc), heel effect (off axis ratio), and quantification of leakagethrough the collimators. All measurements were made so as to utilize theon-board imaging (OBI) at source to surface distances between 50-80 cmto minimize the required mAs per unit dose and thus minimize tube heatloading.

The HVL was determined by measuring collected charge from a farmerchamber placed at the isocenter (100 cm source to surface distance) withthe x-ray tube oriented below the isocenter (at 180°). A 5×5 cm² fieldsize was set, and collected charge was measured at a set mAs withvarying thicknesses of pure aluminum placed on the x-ray housing window(located 14.8 cm from the source).

PDDs were measured at collimator (blade) sizes ranging from 3-32 cm(defined at a distance from the source of 100 cm) and source to surfacedistance of 50 cm and 70 cm using a combination of measurement devicesincluding: optically stimulated luminescence (OSL) dosimeters, aparallel plate chamber (model PPC05, IBA Dosimetry), and gafchromicfilm. Measurements were made both within water and solid water that istissue equivalent within the kV range. When the gafchromic film wasused, it was placed within water at a slight (5°) angle relative to thekV source using a three dimensioned jig, so that the primary beam wasattenuated by water rather than by the film itself; a total dose of 1.52Gy was delivered at the water surface. The film optical density was readout using a flatbed optical scanner at a resolution of 50 dpi using thered channel, and optical density was converted to dose using a measuredcalibration curve.

Sc is the ratio of dose in air measured at a given field size with thatat a reference field size. TG-61 is an AAPM (American Association ofPhysicists in Medicine) protocol for x-ray beam characterization ofdeveloped by the Radiation Therapy Committee Task Group 61, forreference dosimetry of low- and medium energy x rays for radiotherapyand radiobiology (40 kV<tube potential<300 kV). Sc was measured using afarmer chamber and OSLs at an SSD of 50 cm with the reference field sizebeing 10×10 cm (defined at the isocenter).

The backscatter factor (B) is defined as the ratio of dose at thesurface to dose in air, and is dependent on beam quality, field size,and source to surface distance. The backscatter factors B were measuredusing Gafchromic film and OSLs at select field sizes as the ratio ofdose measured at a solid water surface and dose measured for filmsuspended in air with plastic wrap. Backscatter factors for a morecomprehensive set of field sizes were obtained using measurements at thephantom surface measured with a plane-parallel chamber divided by thecollimator scatter factor and normalized using the previously measuredBackscatter factors with a 10 cm field size. The measured backscatterfactors were compared to those tabulated in the AAPM protocol forreference dosimetry in the orthovoltage dose range. These tabulatedvalues are derived from Monte Carlo simulations and include source tosurface distances up to 50 cm. The factors from TG-61 were convertedfrom circular to square fields assuming that the backscatter factor isequivalent for fields with equal areas.

Heel effect was measured using Gafchromic film placed on the surface ofsolid water, located a distance of 50 cm from the source, receiving atotal dose of 1 Gy.

Transmission through the collimator was determined using a farmerchamber near isocenter, and was defined as the ratio of charge collectedwith and without the collimator within the beam path (collimatorclosed).

Formalism for Absolute Dose Calculation in Water:

In one embodiment of the invention, given the measured dosimetric data,the formalism below was used to calculate a dose in water for simple,homogenous geometry. This formalism is expressed in the equation 1below:

${D\left( {{FS},d,l,{SSD}_{treat}} \right)} = {{mAs} \cdot {{OF}_{air}\left( {{FS}_{ref},{SSD}_{ref}} \right)} \cdot \left\lbrack \left( \frac{\overset{\_}{\mu_{en}}}{\rho} \right)_{air}^{w} \right\rbrack_{air} \cdot \frac{{SSD}_{ref}^{2}}{{SSD}_{treat}^{2}} \cdot {B\left( {{FS}_{surface},{SSD}_{treat}} \right)} \cdot {S_{c}\left( {FS}_{blade} \right)} \cdot {{PDD}_{{SSD}_{ref}}\left( {{FS}_{surface},d} \right)} \cdot \left( \frac{{SSD}_{treat} \cdot \left( {{SSD}_{ref} + d} \right)}{{SSD}_{ref} \cdot \left( {{SSD}_{treat} + d} \right)} \right)^{2} \cdot {{OAR}(l)}}$

This formulation was used for calculating the required mAs (beamcurrent) to deliver a dose D to a desired point in water, where OF_(air)is the dose in air per unit mAs at a distance of SSD_(ref) from thesource (80 cm) with a square field size of FS_(ref) (8 cm at 80 cm fromsource). OF_(air) is measured and derived from the TG-61 calibrationprocedure with an ADCL calibrated chamber and includes conversion to airkerma and corrections for temperature, pressure, ion recombination,polarity effect, electrometer accuracy, and stem effect, but does notinclude conversion from dose in air to dose in water nor backscatterfactor. The ratio of average mass energy-absorption coefficients waterto air, free in air, to convert air kerma to water kerma is includedhere and was obtained from Table 4 of the TG-61 report.

Monte Carlo Dose Calculation Including Tissue Heterogeneity:

The formalism above provided the ability for absolute dose calculationin water with a phantom geometry; however at kV energies, the doseeffects of tissue heterogeneity are non-negligible. Because of this, inone embodiment of the invention, a Monte Carlo based treatment planningtool was developed that assessed dose distributions within clinicalsituations. The simulation package used was the FLUKA multi particletransport code version 2005. As noted above, the x-ray tubespecifications including target design, material composition anddensity, and filtration systems were obtained from the manufacturer(Varian Medical Systems, Palo Alto Calif.) and the manufacturer providedMonte Carlo Data Package for the OBI37. The models simulated generationof the 80 kVp spectrum, as shown in FIG. 20B.

In one embodiment of the invention, the electron beam impinging on thetarget was simulated as a parallel rectangular source incident from theside with a monochromatic energy of 80 kV. The large focal spot size, inaccordance with the manufacturer's specifications for the large focalspot, was simulated. In one embodiment of the invention, the cathodegeometry, anode geometry, tube housing, and adjustable X and Y axiscollimators were also simulated according to the manufacturerspecifications. (As a bowtie filter is not used during X-PACT, it wasnot included in the present MC simulations.)

In one embodiment of the invention, the initial model of the OBI systemwas created for the Monte Carlo simulations according to themanufacturer specifications, which was used to calculate the Half ValueLayer (HVL) in aluminum. For the Monte Carlo simulations, the HVL wascalculated as the ratio of dose with and without the layer of aluminumlocated at the Mylar window; the dose was calculated in a 1 cm³ voxel ofwater located 100 cm from the focal spot in order to match themeasurement conditions and the field collimated to a 5 cm×5 cm square inorder to achieve narrow beam geometry. Discrepancies in the measured andMC calculated HVL were then minimized by adjusting (in the model) thelayers of oil, tungsten, and glass that consist of the inherentfiltration from the x-ray housing in the Monte Carlo model.

In one embodiment of the invention, after this tuning of the Monte Carlomodel, the energy spectrum and intensity distribution (heel effect) werecalculated at a distance of 6 cm from the anode, and used to create asecond source geometry model. This simplified model included the photonenergy spectrum recreated at the position of the focal spot, andincluded collimator jaws to shape the field according to the plannedtreatment geometry. The heel effect was modeled by defining sourceintensity as a function of angle using the measured off axis ratio. Inone embodiment of the invention, this second model was then used tocalculate percent depth dose curves, backscatter factors, and collimatorscatter factors, which were compared to their measured counterparts.

In one embodiment of the invention, the Monte Carlo source model wasapplied to a clinical treatment geometry with the X-PACT canine trialincluding an initial CBCT acquired for planning purposes, whichsegmented air, soft tissue, and bone in the CBCT, and then imported thissegmented geometry into the FLUKA Monte Carlo environment for dosecalculation.

Verification Measurements and Results:

As noted above, the model development proceeded by a characterization ofOBI as a X-PACT kV Source. The model includes the geometry of theelectron gun and target enclosed in a vacuum space, and optionallydetails of the aperture emitting x-rays from the vacuum space, thealuminum pre-filter, the lead x-y blades and collimator. The sourcegeometry modeled in the FLUKA Monte Carlo software is illustrated inFIG. 20A.

FIG. 21 is a schematic depiction of x-ray device modeling showingverification of the MC simulation results by measurements of the halfvalue layer for different thicknesses of aluminum and the percent depthdose (PDD) in a water phantom. The agreement with measurement isillustrated in FIG. 21, which shows the measured and modeled attenuationof the beam by varying thicknesses of aluminum (HVL) using a narrow beamgeometry. The HVL was measured to be 3.00±0.04 mm Al. These measurementscompared to the simulated results verify the accuracy of the MCsimulations and the utility of the present inventive approach.

FIG. 22 is a composite schematic showing on the right side verificationof the MC simulations with respect to the off-axis ratio (OAR) of thex-ray energy spectrum emanating from the OBI device at 80 KVp. The leftside of FIG. 22 shows EBT radiochromic film measurements which were madeto determine the back-scatter-factors which are part of thecommissioning data required by AAPM Task Group report TG61.

FIG. 23 is a composite schematic showing verification of the MCsimulations with respect to the back scattered factor (BSF) of the x-rayenergy spectrum emanating from the OBI device at 80 KVp and depositingits energy in a water phantom. The schematic of kV x-ray source modelused for FLUKA Monte Carlo modeling of backscatter factor is shown onleft side, with the source geometry was modeled using the vendor'spublished specifications

(Varian Medical Systems 2010).

In one embodiment of the invention, as shown, the beam is introducedfrom the right-hand side of the canine normal to the direction of thespine. In one embodiment of the invention, the beam is introduced from avariety of different angular directions in order to ascertain forexample which direction provides as much dose to the tumor beforeexceeding the maximum dose permissible in the bone. In one embodiment ofthe invention, the beam stops of the x-ray source are varied to changethe shape of the x-ray bean, and different shapes of beams are evaluatedin order to ascertain for example which shape provides as much dose tothe tumor before exceeding the maximum dose permissible in the bone. Inone embodiment of the invention, the beam energy is varied in order toascertain for example which beam energy provides as much dose to thetumor before exceeding the maximum dose permissible in the bone.

In one embodiment of the invention, the x-ray penetration (or dosedistribution) modeling includes as noted above a distribution of boneand soft tissue including the tumor region being irradiated. The tumorregion includes a distribution of phosphors in the tumor region. In oneembodiment of the invention, the distribution includes a concentrationand concentration profile of the phosphors. In one embodiment of theinvention, the modeling includes information concerning the material ofthe phosphors and their size.

In one embodiment of the invention, MC simulations determine further alight field (UV or visible) emitted from the phosphors upon irradiationwith the x-rays from the modelled x-ray device. In this way, optimizedx-ray dose and phosphor placements maximize the amount of lightgenerated within the tumor region for the medical treatment of thepatient's tumor. Accordingly, in one embodiment of the invention, aMonte Carlo derived x-ray exposure is provided which permits theclinician to set the x-ray device parameters and angle of entry and beamenergy into the patient such that the deposited x-ray energy resides inthe tumor without exceeding the permissible dose in nearby bone or atthe skin.

More specific to the model verification and use of the TG-61 protocol,the dose in air located 80 cm from the source (OF_(air)) was measured tobe 9.58×10⁻³ cGy/mAs for an 80 kVp beam with an 8 cm×8 cm square fieldsize (at 80 cm from the source). Accordingly, the measured relationshipbetween dose per mAs and field size (Sc) is illustrated in FIG. 24,where the nominal field size is defined at 100 cm from the source.Specifically, FIG. 24 is a plot of relative dose in air as a function offield size (Sc) for 80 kVp source at 50 SSD, measured with a farmer ionchamber and measures with the optically stimulated luminescence devicesOSLs. The curve for the OSLs is the logarithmic fit of 67 OSLmeasurements (with 95% confidence interval), which was within 1.5% ofthe ion chamber measurement for nominal field sizes of 5 to 30 cm (at 50SSD), with a maximum difference of 2.3% at a nominal field size of 40cm.

Measured and modeled backscatter factors (B) are plotted in FIG. 25,with square field geometry at a 50 cm distance from the source. For theOSL curve, the ratio was first taken between readings from 37 OSLmeasurements and the average of the OSL and ion chamber collimatorscatter factor curves (from FIG. 24), after which the backscatter OSLmeasurements they were fit with a logarithmic curve (with 95% confidenceinterval). The backscatter factor curves were within 0.7%, 3.4%, and2.4% of the TG-61 data for surface field sizes of 5 to 15 cm for ionchamber, OSLs, and Monte Carlo, respectively. Specifically, FIG. 25 is aschematic showing comparative plots of the ratio of dose on watersurface to dose in air at the same position (backscatter factor), forthe 80 kVp source with a source to detector distance of 50 cm. Themeasurements in FIG. 25 were made with a farmer ion chamber and OSLs,and both indicated increasing dose with field size. 67 OSL measurementswere fit to a logarithmic curve (with 95% confidence interval), whichwas within 1.5% of the ion chamber measurement for nominal field sizesof 5 to 30 cm (at 50 SSD), with a maximum difference of 2.3% at anominal field size of 40 cm. FIG. 25 shows remarkable agreement betweenthe Monte Carlo model and that observed for OSLs, gafchromic film, theparallel plate PP chamber, and TG-61. In one embodiment of theinvention, the backscatter factor comparison noted above is performedprior to treating a patient to verify that the OBI device (or the x-raysource) has not changed.

The measured and modeled depth dose curve(s) for 3×3 cm², an 8×8 cm²,and 32×32 cm² square field sizes (at surface) and an 80 cm SSD areillustrated in FIG. 26. Specifically, FIG. 26 is a schematic depictionof depth dose curves for 80 kVp source at 80 cm source to surfacedistance for 3 cm, 8 cm, and 32 cm field sizes (defined at surface) andnormalized at a depth of 1 cm. Solid points represent measured values,while open points represent Monte Carlo simulations. This x-ray devicemodeling shows verification of the MC simulation results by measurementsof the percent depth dose (PDD) in a water phantom. In one embodiment ofthe invention, the percent depth dose (PDD) verification noted above isperformed prior to treating a patient to verify that the OBI device (orthe x-ray source) has not changed.

Off axis ratio due to heel effect is shown in FIG. 27, which also used a50 cm distance from the source. Specifically, FIG. 27 is a compositeschematic showing verification of the MC simulations with respect to theoff-axis ratio (OAR) of the x-ray energy spectrum emanating from the OBIdevice at 80 KVp. FIG. 27 shows the relative dose at water surface as afunction of off axis distance in the toe-heel axis for 80 kVp sourcewith an SSD of 50 cm. In one embodiment of the invention, the off-axisratio (OAR) verification noted above is performed prior to treating apatient to verify that the OBI device (or the x-ray source) has notchanged.

In general, FIGS. 24-27 are data that is representative of the morecomprehensive set of measured data that was measured to enable dosecalculations with the formalism in Equation 1. The formalism in Equation1 was verified using OSL measurements (N=10) made at various pointswithin solid water, with varying source to surface distances (50-65 cm),field sizes (4×4-11×11 cm²), and treatment depths (0-5 cm). Thedifference between measured and expected dose for these verificationmeasurements was 1%±4% (mean±standard deviation).

FIGS. 28A and 28B show respectively the setup of the dog in the room(first image) and the 3D model of the anatomy from a CBCT (secondimage). This second image is taken is not from the Monte Carlosimulation but shows the type of structure accounted for in the MonteCarlo simulation. The Monte Carlo was used to calculate the dosedistribution. A comparison of these two figures verifies the accuracy ofthe x-ray device model and the x-ray penetration (or dose distribution)modeling. In one embodiment of the invention, the MC simulation to x-rayimage comparison verification noted above is performed prior to treatinga patient to verify that the OBI device (or the x-ray source) has notchanged.

FIG. 29 is a composite depiction showing a final dose calculation usingMonte Carlo modeling and canine CBCT for example case in FIG. 28. Thus,FIG. 29 shows the dose distribution for one dog, overlaid with the CBCTimage of the dog's anatomy.

The results show agreement between the measurements and Monte Carlosimulations for HVL, percent depth dose, and backscatter factor. In oneembodiment of the invention, one or more of these (or other)verification techniques can be used prior to XPACT treatment to ensurethat the x-ray source has not changed its characteristics.

For the 80 kVp beam, the HVL was measured to be 3.00±0.04 mm ofAluminum. Absolute dose in air at 80 cm from the source was 9.58×10⁻³cGy/mAs with an 8 cm×8 cm square field size. At a source to surfacedistance of 80 cm using the same blade settings, the depth dose was71.3%, 37.2%, and 11.8% at 2, 5, and 10 cm, respectively. Collimatorscatter factor was non-negligible, with a 6.3% increase when the fieldsize increased from 10×10 cm to 20×20 cm. The dose calculation handformalism indicated that 21 pulses of 160 mAs were required to deliver aprescription dose at a depth of 1 cm. Measured backscatter factors werealigned within 3.5% of values obtained from the TG-61 protocol. The dosedistribution for a canine X-PACT treatment was calculated with using theMonte Carlo planning tool and visualized at with a 1×1×2 mm³ spatialresolution, and indicated a dose enhancement in hip bone up to 4.5 Gy.

These simulations show the propensity of the x-ray energy to bedeposited into the bone tissue. A top view, side view, and frontal viewis shown. In one embodiment of the invention, as shown, the beam isintroduced from the right-hand side of the canine normal to thedirection of the spine. In one embodiment of the invention, the beam isintroduced from a variety of different angular directions in order toascertain for example which direction provides as much dose to the tumorbefore exceeding the maximum dose permissible in the bone. In oneembodiment of the invention, the beam stops of the x-ray source arevaried to change the shape of the x-ray bean, and different shapes ofbeams are evaluated in order to ascertain for example which shapeprovides as much dose to the tumor before exceeding the maximum dosepermissible in the bone. In one embodiment of the invention, the beamenergy is varied in order to ascertain for example which beam energyprovides as much dose to the tumor before exceeding the maximum dosepermissible in the bone.

In one embodiment of the invention, the x-ray penetration (or dosedistribution) modeling includes (as noted above) a distribution of boneand soft tissue including the tumor region being irradiated. The tumorregion includes a distribution of phosphors in the tumor region. In oneembodiment of the invention, the distribution includes a concentrationand concentration profile of the phosphors. In one embodiment of theinvention, the modeling includes information concerning the material ofthe phosphors and their size.

In one embodiment of the invention, MC simulations determine further alight field (UV or visible) emitted from the phosphors upon irradiationwith the x-rays from the modelled x-ray device. In this way, optimizedx-ray dose and phosphor placements maximize the amount of lightgenerated within the tumor region for the medical treatment of thepatient's tumor. Accordingly, in one embodiment of the invention, aMonte Carlo derived x-ray exposure is provided which permits theclinician to set the x-ray device parameters and angle of entry and beamenergy into the patient such that the deposited x-ray energy resides inthe tumor without exceeding the permissible dose in nearby bone or atthe skin.

Example X-PACT Canine Treatment:

A twelve-year old spayed female beagle dog/canine companion animal witha grade I soft tissue sarcoma overlying the left hip was enrolled in thestudy, and was prescribed to receive 10 fractions of X-PACT, with 5fractions being delivered per week. Prior to treatment, a simulation wasperformed in which a kV CBCT was acquired of the volume of interest andthe attending oncologist veterinarian delineated the clinical tumorvolume (CTV) on the CT image and indicated the depth (at central axis)at which 0.6 Gy was to be prescribed (2.8 cm). A treatment plan wasprepared by defining collimator settings to deliver dose to the CTV withan added 1 cm margin. The 80 kVp irradiation was planned as a singleanterior field at a 50 cm SSD; mAs for beam was determined by anabsolute dose calculation to the prescribed depth (ignoringheterogeneity) from Equation 1, consisting of 21 pulses of 160 mAs.

The planning CBCT was segmented and imported into the FLUKA Monte Carloprogram, and the CBCT intensity values were assigned an effective Zbased on their segmentation (bone, soft tissue, lung, air). A MonteCarlo simulation (1×109 primary histories) was carried out using themachine parameters defined in the treatment plan, and dose wascalculated at 1×1x×2 mm³ resolution and normalized to the prescribeddose point.

At each treatment fraction, the subject was aligned for treatment whileunder anesthesia, and a solution containing co-incubated phosphors andpsoralen were injected directly into the tumor in a grid pattern inorder to achieve a diffused distribution. Immediately after injection,the SSD was set to 70 cm using the optical distance indicator, thetarget volume was aligned to the planned MV light field. The Varianhardware has the capability to shine a light that represents the x-raybeam onto the patient's surface. The planned MV light field is adjustedfor SSD differences between MV and kV sources, and 4 CT compatiblefiducials (for example small metal spheres “BBs”) were place on the skinoutlining the desired treatment area. Next the gantry was rotated by 90°so that the kV source was incident, the kV source was aligned to 80 cmfrom the isocenter (50 cm SSD), and the planned collimator blades wereset to their pre-planned positions and verified under fluoroscopy. Theplanned mAs was then delivered in pulses of 160 mAs each. At the firsttreatment fraction, surface dose was verified via a measurement with anOptically Stimulated Luminescence (OSL) dosimeter, which matched towithin 0.3%. The treatment setup and 3D rendering from the CBCT areshown in FIGS. 28A and 28B, while the isodose overlay on the CBCT isshown in FIG. 29.

The limited penetration of the kV source; for instance, FIG. 26 showsthat at 5 cm the dose is <40% of the surface dose. This limits the depthto which the phosphors can be activated. In one embodiment of theinvention, rotational treatments offer the possibility of extending thetreatments to greater depths. By exposing the deeper regions of thepatient from x-rays coming from sources rotated off a normal axis, theskin exposure can be reduced while the cumulative x-ray dose in thedeeper regions can be increased.

While discussed above with regard to a canine, the present invention isnot so limited and other animal species including human patients canbenefit from this approach.

In one embodiment of the present invention, the treatments and protocolsdescribed above are performed with the assistance of pre-planned MonteCarlo derived x-ray exposures. The Monte Carlo derived x-ray exposuresin one embodiment of the invention permit the settings of the x-raysource and its dose energy and dose flux to be optimized for thelocation and distribution of the tumor (or diseased site) within thebody.

In one embodiment, there is provided a system for treating a disease ina subject in need thereof, which includes a phosphor-containing drugactivator and a photoactivatable drug, one or more devices which infusethe photoactivatable drug and the activator including thepharmaceutically acceptable carrier into a diseased site in the subject;and an x-ray source which is controlled to deliver a pre-planned MonteCarlo derived x-ray exposure to the subject for production ofultraviolet and visible light inside the subject to activate thephotoactivatable drug and preferably induce a persistent therapeuticresponse.

STATEMENTS OF THE INVENTION

The following numbered statements of the invention provide descriptionsof different aspects of the invention and are not intended to limit theinvention beyond that of the appended claims. While presented innumerical order, the present invention recognized that the features setforth below can be readily combined with each other as part of thisinvention. Furthermore, the features set forth below can be readilycombined with any of the elements of the specification discussed above.

1. A phosphor-containing drug activator activatable from a Monte Carloderived x-ray exposure for treatment of a diseased site, comprising:

an admixture or suspension of one or more phosphors capable of emittingultraviolet and visible light upon interaction with x-rays;

wherein a distribution of the phosphors in the diseased target site oran x-ray dose to the diseased site or both is based on a Monte Carloderived x-ray dose. As noted above, phosphors and phosphor combinationsand ratios of different phosphors can be used in the present invention,and the x-ray dose distribution preferably does not exceed a maximumpermissible dose in proximate bone tissue.

2. The activator of statement 1, wherein said phosphors compriseZn₂SiO₄:Mn²⁺ and (3Ca₃(PO₄)₂Ca(F, Cl)₂: Sb³⁺, Mn²⁺) at a ratio from 1:10to 10:1 or ratio from 1:5 to 5:1.

3. The activator of statement 2, wherein said ratio ranges from 1:2 to2:1.

4. The activator of statement 2, wherein said ratio is about 1:2.

5. The activator of statement 1, further comprising 8 MOP.

6. The activator of statement 1, wherein said phosphors have acomposition that emits said ultraviolet and visible light at wavelengthswhich activate 8 MOP.

7. The activator of statement 2, wherein the Monte Carlo derived x-raydose accounts for bone in a vicinity of the diseased site to be treated.

8. The activator of statement 2, wherein said Zn₂SiO₄:Mn²⁺ phosphor hascathodoluminescent emission peaks at 160 nm, 360 nm, and 525 nm and said(3Ca₃(PO₄)₂Ca(F, Cl)₂: Sb³⁺, Mn²⁺) phosphor has a cathodoluminescentemission edge at 400 nm and a cathodoluminescent emission peaks at 570nm.

9. The activator of statement 1, wherein each of said phosphors has afirst coating comprising said ethylene cellulose coating on thephosphor, and a second outer coating comprising said diamond-like carboncoating on said first coating.

10. The activator of statement 1, wherein each of said phosphors has anouter coating of said ethylene cellulose coating.

11. The activator of statement 1, wherein each of said phosphors has anouter coating of said diamond-like carbon coating

12. The activator of statement 10, wherein said ethylene cellulosecoating is present and has a thickness between 10 and 100 nm.

13. The activator of statement 10, wherein said ethylene cellulosecoating is present and has a thickness between 30 and 60 nm.

14. The activator of statement 11, wherein said diamond-like carboncoating is present and has a thickness between 50 and 200 nm.

15. The activator of statement 11, wherein said diamond-like carboncoating is present and has a thickness between 75 and 125 nm.

16. The activator of statement 2, wherein said Zn₂SiO₄:Mn²⁺ phosphor hasa size between 0.05 and 100 microns.

17. The activator of statement 2, wherein said Zn₂SiO₄:Mn²⁺ phosphor hasa size between 0.1 and 50 microns.

18. The activator of statement 2, wherein said Zn₂SiO₄:Mn²⁺ phosphor hasa size between 0.5 and 20 microns.

19. The activator of statement 2, wherein said (3Ca₃(PO₄)2Ca(F, Cl)₂:Sb³⁺, Mn²⁺) phosphor has a size between 0.05 and 100 microns.

20. The activator of statement 2, wherein said (3Ca₃(PO₄)2Ca(F, Cl)₂:Sb³⁺, Mn²⁺) phosphor has a size between 0.1 and 50 microns.

21. The activator of statement 2, wherein said (3Ca₃(PO₄)2Ca(F, Cl)₂:Sb³⁺, Mn²⁺) phosphor has a size between 0.5 and 20 microns.

22. The activator of statement 1, which is a suspension and wherein saidphosphors and the pharmaceutically acceptable carrier comprise a sterilesolution.

23. The activator of statement 22, wherein a ratio of phosphor weight tovolume of the sterile suspension ranges from 1 to 50 mg/mL.

24. The activator of statement 22, wherein a ratio of phosphor weight tovolume of the sterile suspension ranges from 5 to 25 mg/mL.

25. The activator of statement 22, wherein a ratio of phosphor weight tovolume of the sterile suspension ranges from 8 to 10 mg/mL.

26. The activator of statement 1, wherein the Monte Carlo derived x-raydose is derived from at least one of a model of an x-ray source or amodel of the diseased site including bone structures present therein.

27. The activator of statement 1, further comprising an additiveproviding a therapeutic or diagnostic effect.

28. The activator of statement 27, wherein the additive comprises atleast one of an antioxidant, an adjuvant, or a combination thereof.

29. The activator of statement 27, wherein the additive comprises animage contrast agent.

30. The activator of statement 27, wherein the additive comprises avaccine.

31. A system for treating a disease in a subject in need thereof,comprising:

the activator of one of statements 1-30 or combinations thereof;

a photoactivatable drug;

one or more devices which infuse the photoactivatable drug and theactivator including the pharmaceutically acceptable carrier into adiseased site in the subject; and

an x-ray source which is controlled to deliver said Monte Carlo derivedx-ray exposure to the subject for production of the ultraviolet andvisible light inside the subject to activate the photoactivatable drugand induce a persistent therapeutic response, said dose comprising apulsed sequence of x-rays delivering from 0.5-2 Gy to the tumor.

32. The system of statement 31, wherein the photoactivatable drug isuntethered from the phosphors.

33. The system of statement 31, wherein the one or more devicesadminister the photoactivatable drug in accordance with a volume of thediseased site.

34. The system of statement 31, wherein

an amount of the phosphors in the pharmaceutical carrier ranges from 0.1to 0.66 milligrams of phosphor per cm³ of the volume of the diseasedsite, and

a concentration of the photoactivatable drug in the pharmaceuticalcarrier ranges from 10 μg/mL to 50 μg/mL.

35. The system of statement 31, wherein the x-ray source is configuredto generate x-rays from a peak applied cathode voltage at or below 300kVp, at or below 200 kVp, at or below 120 kVp, at or below 105 kVp, ator below 80 kVp, at or below 70 kVp, at or below 60 kVp, at or below 50kVp, at or below 40 kVp, at or below 30 kVp, at or below 20 kVp, at orbelow 10 kVp, or at or below 5 kVp.

36. The system of statement 31, wherein the dose of x-rays comprises anamount to cause an auto-vaccine effect in the human or animal body.

37. The system of statement 31, wherein the x-ray source is controlledduring a booster treatment to repeat on a periodic basis a treatment ofthe diseased site.

38. The system of statement 37, wherein, in the booster treatment, atleast one of phosphor concentration, photoactivatable drugconcentration, and the radiation dose is increased by a factor of atleast two times, five times, or ten times respective initial values.

39. The system of statement 37, wherein the booster treatment producespsoralen-modified cancer cells or X-ray modified cancer cells.

40. The system of statement 37, wherein the booster treatment producesradiation damaged cancer cells.

41. The system of statement 37, wherein a period between boostertreatments is delayed according to a tolerance level of the human oranimal body for radiation-modified cells generated during the boostertreatment.

42. The system of statement 31, wherein the x-ray source directs x-raysto at least one of a tumor or a malignancy.

43. The system of statement 31, wherein the x-ray source directs x-raysto at least one of a eukaryotic cell, a prokaryotic cell, a subcellularstructure, an extracellular structure, a virus or prion, a cellulartissue, a cell membrane, a nuclear membrane, cell nucleus, nucleic acid,mitochondria, ribosome, or other cellular organelle.

44. The system of statement 31, wherein the x-ray source directs x-raysto a diseased site in a pulsed manner having an on and off time.

45. The system of statement 44, wherein the x-ray source directs x-raysto the diseased site such that the on time activates the phosphor andthe off time is long enough for decay of phosphor light emission.

46. The system of statement 31, wherein the x-ray source directs x-raysto a tumor or a malignancy in a pulsed manner having an on and off time.

47. The system of statement 46, wherein the x-ray source directs x-raysto the tumor or the malignancy such that the on time activates thephosphor and the off time is long enough for decay of phosphor lightemission.

48. The system of statement 31, wherein the x-ray source directs x-raysto the diseased site according to a predetermined radiation protocolsuch that a predetermined change occurs in the diseased site.

49. The system of statement 48, wherein said predetermined changecomprises at least one of 1) affects a prion, viral, bacterial, fungal,or parasitic infection, 2) comprises at least one of one of tissueregeneration, inflammation relief, pain relief, immune systemfortification, or 3) comprises at least changes in cell membranepermeability, up-regulation and down-regulation of adenosinetriphosphate and nitric oxide.

50. The system of statement 31, wherein the x-ray source is controlledsuch that a dose of about 1 Gy is delivered using twenty one x-raypulses spaced apart by 10 seconds; and, each x-ray pulse of 800 ms isdelivered from the x-ray source set at a voltage of 80 kV and anamperage of 200 mA.

51. A method for treating a disease in a subject in need thereof usingthe system of statement 31, comprising:

infusing the photoactivatable drug, and the activator including thepharmaceutically acceptable carrier into a diseased site in the subject;and

delivering said Monte Carlo derived x-ray exposure to the subject forproduction of the ultraviolet and visible light inside the subject toactivate the photoactivatable drug and induce a persistent therapeuticresponse, said dose comprising a pulsed sequence of x-rays deliveringfrom 0.5-2 Gy to the tumor.

52. The method of statement 51, wherein infusing comprises infusing thephotoactivatable drug untethered from the phosphors.

53. The method of statement 51, wherein infusing comprises administeringthe photoactivatable drug in accordance with a volume of the diseasedsite.

54. The method of statement 51, wherein

an amount of the phosphors in the pharmaceutical carrier ranges from 0.1to 0.66 milligrams of phosphor per cm³ of the volume of the diseasedsite, and

a concentration of the photoactivatable drug in the pharmaceuticalcarrier ranges from 10 μg/mL to 50 μg/mL.

55. The method of statement 51, wherein delivering comprises generatingx-rays from a peak applied cathode voltage at or below 300 kVp, at orbelow 200 kVp, at or below 120 kVp, at or below 105 kVp, at or below 80kVp, at or below 70 kVp, at or below 60 kVp, at or below 50 kVp, at orbelow 40 kVp, at or below 30 kVp, at or below 20 kVp, at or below 10kVp, or at or below 5 kVp.

56. The method of statement 51, wherein delivering comprises providing adose of x-rays in an amount to cause an auto-vaccine effect in the humanor animal body.

57. The method of statement 51, wherein delivering comprises providing abooster treatment which repeats on a periodic basis a treatment of thediseased site.

58. The method of statement 57, wherein, in the booster treatment, atleast one of phosphor concentration, photoactivatable drugconcentration, and the radiation dose is increased by a factor of atleast two times, five times, or ten times respective initial values.

59. The method of statement 57, wherein the booster treatment producespsoralen-modified cancer cells or X-ray modified cancer cells.

60. The method of statement 57, wherein the booster treatment producesradiation damaged cancer cells.

61. The method of statement 57, wherein a period between boostertreatments is delayed according to a tolerance level of the human oranimal body for radiation-modified cells generated during the boostertreatment.

62. The method of statement 51, wherein delivering comprises at leastone of:

directing x-rays to instrumentation for verification of the Monte Carloderived x-ray exposure;

verifying the Monte Carlo derived x-ray exposure; and

directing x-rays to a diseased site such as at least one of a tumor or amalignancy.

63. The method of statement 51, wherein delivering comprises directingx-rays to at least one of a eukaryotic cell, a prokaryotic cell, asubcellular structure, an extracellular structure, a virus or prion, acellular tissue, a cell membrane, a nuclear membrane, cell nucleus,nucleic acid, mitochondria, ribosome, or other cellular organelle.

64. The method of statement 51, wherein delivering comprises directingx-rays to a diseased site in a pulsed manner having an on and off time.

65. The method of statement 64, wherein delivering comprises directingx-rays to the diseased site such that the on time activates the phosphorand the off time is long enough for decay of phosphor light emission.

66. The method of statement 51, wherein delivering comprises directingx-rays to a tumor or a malignancy in a pulsed manner having an on andoff time.

67. The method of statement 66, wherein delivering comprises directingx-rays to the tumor or the malignancy such that the on time activatesthe phosphor and the off time is long enough for decay of phosphor lightemission.

68. The method of statement 51, wherein delivering comprises directingx-rays to the diseased site according to a predetermined radiationprotocol such that a predetermined change occurs in the diseased site.

69. The method of statement 68, wherein said predetermined changecomprises at least one of 1) affects a prion, viral, bacterial, fungal,or parasitic infection, 2) comprises at least one of one of tissueregeneration, inflammation relief, pain relief, immune systemfortification, or 3) comprises at least changes in cell membranepermeability, up-regulation and down-regulation of adenosinetriphosphate and nitric oxide.

70. The method of statement 51, wherein delivering comprises providing adose of about 1 Gy using twenty one x-ray pulses spaced apart by 10seconds; and, each x-ray pulse of 800 ms is delivered from an x-raysource set at a voltage of 80 kV and an amperage of 200 mA.

71. A method for treating a disease in a subject in need thereof usingthe system of statement 31, comprising:

prior to treating the disease, performing a Monte Carlo calculation toascertain an x-ray energy distribution inside a target site of thedisease; and

delivering x-rays into the target site with an energy spectrum anddirection determined by the Monte Carlo calculation.

72. The method of statement 71, wherein performing a Monte Carlocalculation comprises introducing a modeled beam of x-rays fromdifferent angular directions in order to ascertain which directionprovides a dose to the tumor before exceeding a maximum dose permissiblein nearby bone tissue.

73. The method of statement 71, wherein performing a Monte Carlocalculation comprises introducing a modeled beam of x-rays fromdifferent shaped beams in order to ascertain which beam shape provides adose to the tumor before exceeding a maximum dose permissible in nearbybone tissue.

74. The method of statement 71, wherein performing a Monte Carlocalculation comprises introducing a modeled beam of x-rays fromdifferent peak beam energies in order to ascertain which peak beamenergy provides a dose to the tumor before exceeding a maximum dosepermissible in nearby bone tissue

75. The method of statement 71, wherein performing a Monte Carlocalculation comprises modeling the x-ray penetration or absorbed dosedistribution in the target site.

76. The method of statement 75, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling a distribution of bone and soft tissue including atumor region to be treated.

77. The method of statement 75, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling a concentration profile of the one or more phosphors inthe tumor region.

78. The method of statement 75, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling a material and size of the one or more phosphors.

79. The method of statement 75, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling an emitted light distribution from the one or morephosphors.

80. A method for treating a disease in a subject in need thereof usingthe system of statement 31, comprising:

prior to treating the disease, performing a Monte Carlo calculation toascertain an x-ray energy distribution inside a target site of thedisease; and

delivering the activator to the target site of the disease in adistribution within the target site as determined by the Monte Carlocalculation.

81. The method of statement 80, wherein performing a Monte Carlocalculation comprises introducing a modeled beam of x-rays fromdifferent angular directions in order to ascertain which directionprovides a dose to the tumor before exceeding a maximum dose permissiblein nearby bone tissue.

82. The method of statement 80, wherein performing a Monte Carlocalculation comprises introducing a modeled beam of x-rays fromdifferent shaped beams in order to ascertain which beam shape provides adose to the tumor before exceeding a maximum dose permissible in nearbybone tissue.

83. The method of statement 80, wherein performing a Monte Carlocalculation comprises introducing a modeled beam of x-rays fromdifferent peak beam energies in order to ascertain which peak beamenergy provides a dose to the tumor before exceeding a maximum dosepermissible in nearby bone tissue

84. The method of statement 80, wherein performing a Monte Carlocalculation comprises modeling the x-ray penetration or absorbed dosedistribution in the target site.

85. The method of statement 84, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling a distribution of bone and soft tissue including atumor region to be treated.

86. The method of statement 84, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling a concentration profile of the one or more phosphors inthe tumor region.

87. The method of statement 84, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling a material and size of the one or more phosphors.

88. The method of statement 84, wherein modeling the x-ray penetrationor absorbed dose distribution in the target site comprises accommodatingin the modelling an emitted light distribution from the one or morephosphors.

89. A system for treating a disease in a subject in need thereof,comprising: a phosphor-containing drug activator and a photoactivatabledrug, one or more devices which infuse the photoactivatable drug and theactivator optionally including a pharmaceutically acceptable carrierinto a diseased site in the subject, and an x-ray source which iscontrolled to deliver a Monte Carlo derived x-ray exposure to thesubject for production of ultraviolet and visible light inside thesubject to activate the photoactivatable drug.

90. The system of statement 89 utilizing any of the activator ofstatements 1-30, the system components of statements 31-50, and/orimplementing any of the methods of statements 51-88.

Numerous modifications and variations of the invention are possible inlight of the above teachings. It is therefore to be understood thatwithin the scope of the appended claims, the invention may be practicedotherwise than as specifically described herein. All of thepublications, references, patents, patent applications, and otherdocuments identified above are incorporated by reference herein in theirentirety.

The invention claimed is:
 1. A method for treating a disease in a subject in need thereof, comprising: prior to treating the disease, performing a Monte Carlo calculation to ascertain an x-ray energy distribution inside a target site of the disease; and delivering a phosphor-containing drug activator and a photoactivatable drug to the target site of the disease in a distribution within the target site as determined by the Monte Carlo calculation, wherein the phosphor-containing drug activator is activatable from the Monte Carlo calculation derived x-ray exposure for treatment of the target site of the disease, wherein the phosphor-containing drug activator comprises: an admixture or suspension of one or more phosphors capable of emitting ultraviolet and visible light upon interaction with x-rays; wherein a distribution of the phosphors in the diseased target site or an x-ray dose to the diseased site or both is based on the Monte Carlo calculation derived x-ray dose.
 2. The method of claim 1, wherein performing a Monte Carlo calculation comprises introducing a modeled beam of x-rays from different angular directions in order to ascertain which direction provides a dose to the target site of the disease before exceeding a maximum dose permissible in nearby bone tissue.
 3. The method of claim 1, wherein performing a Monte Carlo calculation comprises introducing a modeled beam of x-rays from different shaped beams in order to ascertain which beam shape provides a dose to the target site of the disease before exceeding a maximum dose permissible in nearby bone tissue.
 4. The method of claim 1, wherein performing a Monte Carlo calculation comprises introducing a modeled beam of x-rays from different peak beam energies in order to ascertain which peak beam energy provides a dose to the target site of the disease before exceeding a maximum dose permissible in nearby bone tissue.
 5. The method of claim 1, wherein performing a Monte Carlo calculation comprises modeling the x-ray penetration or absorbed dose distribution in the target site.
 6. The method of claim 5, wherein modeling the x-ray penetration or absorbed dose distribution in the target site comprises accommodating in the modeling a distribution of bone and soft tissue including a tumor region to be treated.
 7. The method of claim 5, wherein modeling the x-ray penetration or absorbed dose distribution in the target site comprises accommodating in the modeling a concentration profile of the one or more phosphors in the target site.
 8. The method of claim 5, wherein modeling the x-ray penetration or absorbed dose distribution in the target site comprises accommodating in the modeling a material and size of the one or more phosphors.
 9. The method of claim 5, wherein modeling the x-ray penetration or absorbed dose distribution in the target site comprises accommodating in the modeling an emitted light distribution from the one or more phosphors.
 10. The method of claim 1, wherein said one or more phosphors comprise Zn₂SiO₄:Mn²⁺ and (3Ca₃(PO₄)₂Ca(F, Cl)₂: Sb³⁺, Mn²⁺) at a ratio from 1:10 to 10:1 or ratio from 1:5 to 5:1.
 11. The method of claim 10 wherein said ratio ranges from 1:2 to 2:1.
 12. The method of claim 10, wherein said ratio is about 1:2.
 13. The method of claim 1, wherein said phosphors have a composition that emits said ultraviolet and visible light at wavelengths which activate 8-methoxypsoralen (8-MOP).
 14. The method of claim 10, wherein said Zn₂SiO₄:Mn²⁺ phosphor has cathodoluminescent emission peaks at 160 nm, 360 nm, and 525 nm.
 15. The method of claim 10, wherein said (3Ca₃(PO₄)₂Ca(F, Cl)₂: Sb³⁺, Mn²⁺) phosphor has a cathodoluminescent emission edge at 400 nm and a cathodoluminescent emission peaks at 570 nm.
 16. The method of claim 1, wherein each of said one or more phosphors has a first coating comprising said ethylene cellulose coating on the phosphor, and a second outer coating comprising said diamond-like carbon coating on said first coating.
 17. The method of claim 1, wherein each of said one or more phosphors has an outer coating of said ethylene cellulose coating.
 18. The method of claim 1, wherein each of said one or more phosphors has an outer coating of said diamond-like carbon coating.
 19. The method of claim 17, wherein said ethylene cellulose coating is present and has a thickness between 10 and 100 mn.
 20. The method of claim 17, wherein said ethylene cellulose coating is present and has a thickness between 30 and 60 nm.
 21. The method of claim 18, wherein said diamond-like carbon coating is present and has a thickness between 50 and 200 nm.
 22. The method of claim 18, wherein said diamond-like carbon coating is present and has a thickness between 75 and 125 nm.
 23. The method of claim 10, wherein said Zn₂SiO₄:Mn²⁺ phosphor has a size between 0.05 and 100 microns.
 24. The method of claim 10, wherein said Zn₂SiO₄:Mn²⁺ phosphor has a size between 0.1 and 50 microns.
 25. The method of claim 10, wherein said Zn₂SiO₄:Mn²⁺ phosphor has a size between 0.5 and 20 microns.
 26. The method of claim 10, wherein said (3Ca₃(PO₄)2Ca(F, Cl)₂: Sb³⁺, Mn²⁺) phosphor has a size between 0.05 and 100 microns.
 27. The method of claim 10, wherein said (3Ca₃(PO₄)2Ca(F, Cl)₂: Sb³⁺, Mn²⁺) phosphor has a size between 0.1 and 50 microns.
 28. The method of claim 10, wherein said (3Ca₃(PO₄)2Ca(F, Cl)₂: Sb³⁺, Mn²⁺) phosphor has a size between 0.5 and 20 microns.
 29. The method of claim 1, wherein the target site is a tumor.
 30. The method of claim 2, wherein the target site is a tumor.
 31. The method of claim 3, wherein the target site is a tumor.
 32. The method of claim 4, wherein the target site is a tumor.
 33. The method of claim 7, wherein the target site is a tumor. 